Non vital pulp therapy

NON VITAL PULP THERAPY
By Dr. Lilavanti Vaghela
MDS in Pediatric and Preventive Dentistry

Content
• Definition
• Indications
• Contraindications
• Historical perspective
• Clinical pulpal diagnosis
• Procedure
• Single visit
• Multiple visit

• Steps in pulpectomy
• Anesthesia, isolation and access opening
• Working length measurement
• Cleaning and shaping the canals
• Irrigation
• Obturation
• Materials for obturation
• studies
• Obturation techniques
• Studies
• Clinical and radiographic success
• Conclusion
• References

Definition
• Mathewson(1995)- The complete removal of the necrotic pulp from the root
canals of primary teeth and filling them with an inert resorbable material so as to
maintain the tooth in the dental arch.
• Finn- Removal of all pulpal tissue from the coronal and radicular portions of the
tooth.
• Dannenburg 1974-the extirpation of the vital pulp, normal or abnormal followed
by sterilization and filling of the root canal.

Difficult in primary dentition because,
• Complexity & irregularity of canals
• Accessory canals
• Ongoing resorption
• Inability to determine anatomical apex
Although pulpectomy is the total removal of the pulp tissue from the root canals; this
cannot be achieved in the primary dentition, because of the complexity and irregularity
of the root canals and the inability to determine an anatomical apex as in the permanent
teeth. It is suggested therefore that the term pulpectomy should not be used in
endodontic treatment of primary teeth. The procedure should be termed therefore as
"Pulp canal treatment" or as "Partial pulpectomy" as it is not possible to remove
complete pulp tissue from the delicate network of canals.

Rationale
• To gain access to the root canals
• To remove as much as dead and infected material as possible
• Fill root canals with a suitable material to maintain primary tooth in a non-
infected
Treatment Objectives
• Maintain tooth free of infection
• Biomechanically cleanse & obturate root canals
• Promote physiologic root resorption
• Hold space for the erupting permanent tooth

• Primary Goal
✓To eliminate infection and retain the tooth in a functional state until it is normally
exfoliated, without endangering the permanent dentition or the health of the
child - Garcia–Godoy (1987)
✓Successful treatment of pulpally involved tooth is to retain it in a healthy
condition so it may fulfill its role as a useful component of primary and young
permanent dentition - Lewis and Law

• Pediatric dentistry is a unique specialty that deals with the total and
comprehensive oral health care of children.
• Historically, pediatric dentistry has evolved from an extraction-oriented
practice at the beginning, where primary teeth with inﬂamed pulps were
mostly extracted, and no focus has been put on preserving the pulp, to a
specialty based on emphasizing prevention of oral and dental diseases
Pediatric Endodontics Current Concepts in Pulp Therapy for Primary and Young Permanent
Teeth, Anna B. Fuks ,Benjamin Peretz
HISTORY

• A more conservative approach has been developed during the last decades
regarding dental caries and speciﬁc modes of treatment such as minimal
invasive dentistry and an increase use of prevention materials.
• This approach has been attributed to both developed diagnostic criteria
and tools and to the new dental products and materials in the market.
• This approach goes further with regard to pulp therapy.

• It has long been established that the human dental pulp has a remarkable
potential for self-healing when encountering a severe insult, especially in
young patients, mainly due to the high degree of cellularity and vascularity.
• Incomplete caries removal, stepwise excavation, and indirect pulp
treatment have been proposed to treat reversibly inﬂamed pulps.
• In addition, several techniques for managing irreversibly inﬂamed or
necrotic pulps have been introduced in pediatric dentistry practice.
Pediatric Endodontics Current Concepts in Pulp Therapy for Primary and Young Permanent Teeth, Anna B. Fuks
,Benjamin Peretz

“The success of the treatment (vital/non vital pulp
therapy) used to depends mainly upon an accurate
preoperative assessment of pulp status”.

• The diagnosis of pulp necrosis is then reached, and treatment decision of
extraction or root canal therapy is based on
• the restorability of the tooth
• severity of the infection
• assessment of bone loss
• lesion proximity to the succedaneus tooth follicle
• and patient cooperation

Clinical Pulpal Diagnosis
Medical History
• A child with a systemic disease needs a different approach than a healthy
one.
• Despite lack of evidence, for severely immunocompromised patients, the
American Academy of Pediatric Dentistry (AAPD) recommends cautious
considerations when treating deep carious lesions with close proximity to
the pulp.

• When the pulp is involved, most clinicians decide to perform a more radical
procedure such as an extraction, rather than performing a conservative
treatment dealing with the risk of infections which might be life
threatening.
• However, with existing pulpally treated teeth, periodic monitoring for signs
of internal resorption or failure due to pulpal/ periapical/furcal infections is
recommended.

Extra- and Intraoral Examination
Swelling
• Swelling may present intraorally , localized to infected tooth or extraorally
in the form of cellulities.
CURZON M,ROBERTS J,KENNEDY D,KENNEDY’S PEDIATRIC OPERATIVE DENTISTRY,4TH EDITION

• It is caused by the inflammatory exudate associated with non vital tooth.
• Since swelling may not exist at the time of examination the clinician must
thoroughly question both child and parent to uncover any history of
swelling.
• The relationship of muscle attachments, particularly that of the
buccinator , to the inter radicular and periapical areas determines
whether the swelling has an intraoral or extraoral location.

• The presence of swelling does not necessarily indicate that an extraction is
needed, as with antibiotic therapy the swelling can be resolved and pulp
therapy initiated, often within 72 hrs
- Peterson and Curzon,1992

• Intraoral swelling is usually apparent on the buccal aspect , in rare
instances present lingually / palatally.
• There is less buccal than lingual bone through which the inflammatory
products from the periapical or inter radicular regions penetrate, taking
path of least resistance.
• Most commonly drainage occurs intraorally either via the gingival margin
or by the establishment of fistula.

• It is generally seen at or near the junction of the attached gingiva and
alveolar mucosa, as that site is adjacent to the inter radicular region where
the inflammatory products are normally located in non vital primary
molars

• In mandibular arch, the mandibular region is commonly involved as a result
of non vital second primary or 1st PM.
• In maxillary arch the swelling from non vital primary canines and first
primary molars can be so severe as to close the child’s eye.

• The pulp of a tooth having either an intra or extra oral swelling or fistula
will be non vital.
• However, it is possible for vital tissue, although inflamed, to be present in
one canal while an adjacent canal will be non vital ; the fistula will be
adjacent to the non vital canal.
• For treatment purpose, the whole pulp must be considered non vital.
• However, because there may still be some vital tissue left, this means that
LA should be used during treatment.

• In severe situations, facial cellulitis may involve the infraorbital space
resulting in partial/total closure of the eye, limited mouth opening, fever,
and malaise.
• Careful intraoral and radiographic examination seeking teeth with deep
carious lesions or deep restorations must be performed.

• During intraoral examination, the clinician should perform a careful soft
tissue assessment searching for signs of swelling of the vestibule, presence
of sinus tracts which may be associated with teeth affected by trauma,
caries, or deep restorations in close proximity to the pulp.
• When examining hard tissues, teeth with questionable diagnosis should be
evaluated for abnormal mobility and sensitivity to percussion.
• With the presence of open proximal carious lesions between adjacent
teeth, the space can serve as reservoir causing food impaction providing
false-positive response to percussion test.

• In order to avoid behavior management problems, when performing
percussion and palpation tests in children, the tip of the ﬁnger should be
gently used in combination with Tell, Show, and Do (TSD) technique.
• The clinician should start the test with a contralateral non-affected tooth
to familiarize the patient with a normal response to the stimuli.

Pain Characteristics
• An accurate history must be obtained of the type of pain experienced
including its duration, frequency, location and spread as well as
aggravating and relieving factors.
• As pain is subjective, the clinician must be aware of the varing responses
given by the child and parents.
Kennedy’s operative pediatric dentistry, 4th edition

• A fearful child may have been kept awake the previous night with a
toothache only to report that he or she has no pain when faced with the
immediate dental experience.
• On the other hand, a parent who has neglected seeking dental care for the
child may describe agonizing pain of 3weeks duration in the hope that the
comprehensive care will be performed immediately for the child.
• Indeed, it is often difficult to elicit an accurate history from the parents.

• The absence of toothache does not preclude a histologic pulpitis, either in
primary / permanent teeth
-Hobson, Hasler and Mitchell
• Eg, children are seen who have non vital primary molars with fistulae,
although their parents will truthfully deny history of toothache.
• Severity of pain can probably be attributed to increased pressure within
the enclosed hard tissue confines of the tooth and supporting structures.

• A positive h/o toothache suggests definite pulp pathology.
• However, it is difficult to correlate the type of pain with the degree of
pathosis.
• Sensitivity to thermal stimuli indicates that the pulp is vital.
• The immediate response to hot or cold that disappear on removal of the
stimuli ( momentary pain) indicates that the pathosis is limited to the
coronal pulp.

• Momentary pain is response to thermal stimuli may also be due to the
exposure of dentine from a leaking restoration or an open lesion , sealing
the exposed dentin may relieve this type of pain.
• Persistent pain from thermal stimuli would indicate widespread
inflammation of the pulp, extending into the radicular filaments to
contraindicate single visit pulpotomy
-Koch and Nyborg , 1970

• Spontaneous pain in primary teeth has been linked with extensive
inflammation extending throughout the radicular filaments and
microscopic internal resorption in the root canal
- Gutherie at al, 1965

• Young children are not good historians.
• For this group, parents are the ones better prepared to reporting existing
symptoms.
• Stimuli-related responses that cease when the insult is removed (provoked
or elicited pain) generally indicate a favorable, reversible status of the pulp
which could lead to a more conservative treatment approach such as
indirect pulp therapy (IPT) or pulpotomy.

• Complaints of persistent, lingering, or throbbing pain disturbing sleep and
preventing regular activity are generally referred as “spontaneous pain.”
• This most probably indicates an irreversible status of the pulp.
• The information in combination with clinical examination and radiographic
image will lead the clinician to treatment options such as pulpectomy or
extraction.

Mobility
• It may result from physiological or pathological cause.
• R/g evaluation of the remaining root of a primary tooth, the crown position
and the amount of root formation of the underlying permanent successor
will determine whether any mobility is physiological or pathological.
• Physiological root resorption of more than one half the root length
contraindicates the pulp therapy and extraction should be considered .

• Pathological mobility is due to root or bone resorption or both and
associated with non vital pulp.
• Bone resorption is identified radiographically by a periapical or inter
radicular radiolucency or both, most commonly in furcal area.

Percussion
• Pain from pressure on a tooth indicates that supporting periodontal
structures are inflamed.
• Depression of tooth into this inflamed tissue results in this type of pain.
• Occasionally the radiograph will demonstrate that the tooth has been
slightly extruded from its socket and it is in premature occlusion.

• As the teeth occlude, the inflamed tissue around the apex is irritated by
percussion.
• As with pathological mobility, pain from percussion indicates that the tooth
is most likely non vital and that the surrounding periodontium is inflamed.
• It is possible, however , to have an inflamed , vital pulp associated with
apical periodontitis in permanent teeth
- seltzer et al,1963

Sensibility Tests
• Sensibility and percussion tests are not indicated in primary teeth due to
inconsistent results.
• Younger patients may also be more anxious and less reliable because of
the subjective nature of the test.
• The most commonly used pulpal sensibility tests are cold and electric pulp
tester (EPT).
• For a reliable response, teeth need to be dried and well isolated. Adjacent
and/or contralateral teeth to the one in question are generally tested ﬁrst,
as controls, to observe a baseline normal response.
Jespersen JJ, Hellstein J, Williamson A, Johnson WT, Qian F. Evaluation of dental pulp sensibility
tests in a clinical setting. J Endod. 2014;40:351–4.

• Refrigerant spray is the most commonly used. It is convenient, user-
friendly, and reliable with a level of accuracy higher than EPT.
• The cold test may be used to differentiate between reversible and
irreversible pulpitis.
• If pain subsides when the stimulus is removed, a diagnosis of reversible
pulpitis is appropriate. If lingering pain persists, irreversible pulpitis is more
likely.
• Jespersen et al. evaluated the pulpal response to cold and EPT in the
presence and absence of caries. They found that presence of caries in vital
teeth resulted in a more accurate response to cold testing. However, no
response to cold on carious teeth makes a diagnosis of pulpal necrosis
more accurate.
Jespersen JJ, Hellstein J, Williamson A, Johnson WT, Qian F. Evaluation of dental pulp sensibility
tests in a clinical setting. J Endod. 2014;40:351–4.

Exposure site
• Both the size of the exposure site and the nature of exudate expressed
from it are useful diagnostic aids
- Koch and Nyborg,1970
• Light red blood and haemorrhage that can be arrested easily are associated
with inflammation that limited to the coronal pulp in primary teeth.
• Profuse haemorrhage from exposure site, with deep red blood, is
histologically associated with inflammation extending into the root canals.
So in this case pulpectomy should perform.

AAPD GUILDLINES
Indications:
• A pulpectomy is indicated in a primary tooth with irreversible pulpitis or
necrosis or a tooth treatment planned for pulpotomy in which the radicular
pulp exhibits clinical signs of irreversible pulpitis (e.g., excessive
hemorrhage that is not controlled with a damp cotton pellet applied for
several minutes) or pulp necrosis (e.g., suppuration, purulence).
• The roots should exhibit minimal or no resorption.
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY REFERENCE MANUAL V 4 0 / N O 6 1 9/ 20

Objectives
• Following treatment, the radiographic infectious process should resolve in
six months, as evidenced by bone deposition in the pretreatment
radiolucent areas, and pre-treatment clinical signs and symptoms should
resolve within a few weeks.
• There should be radiographic evidence of successful filling without gross
overextension or under-filling.
• The treatment should permit resorption of the primary tooth root and
filling material to permit normal eruption of the succedaneous tooth.
• There should be no pathologic root resorption or furcation/apical
radiolucency.
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY REFERENCE MANUAL V 4 0 / N O 6 1 9/ 20

Indications
• Primary teeth with pulpal inflammation extending beyond the coronal pulp
but with roots and alveolar bone free of pathologic resorption.
• Primary teeth with necrotic pulps, minimum root resorption, and minimum
bony destruction in bifurcation area.

• Primary teeth with evidence of furcation pathology
• Presence of abscess
• Teeth with poor chance of vital pulp treatment

Indications
• A non vital tooth associated with an abscess or fistula
• Presence of pus at the exposure site or in the pulp chamber
• Cellulitis
• Extensive furcation pathology
• Radicular pulp is chronically inflamed
• If pain present may be spontaneous or persistent
• The tooth is restorable

• Mobility or intraradicular bone loss are minimal
• The haemorrhage from the amputation site is dark red and scanty ,difficult to
control
• Primary teeth without permanent successor
STEWART R,BARBER T,TROUTMAN K,WEI S,PEDIATRIC DENTISTRY,SCIENTIFIC FOUNDATIONS
AND CLINICAL PRACTICE,1982

Major Contraindications
• Unrestorable crown
• Advanced pathological root resorption

Other Contraindications
• Periradicular involvement extending to the permanent tooth bud
• Pathologic resorption of at least 1/3rd of root with a fistulous sinus tract
• Excessive internal resorption
• Extensive pulp floor opening into bifurcation
• Primary teeth with underlying dentigerous or follicular cysts

• Excessive tooth mobility
• Furcation involvement
• External root resorption
• Internal root resorption
• Gross loss of root structure
• Periapical infection involving the crypts of succadenous tooth
Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5th edition. Elsevier.Mosby

Medical contraindication
✓Heart disease
• a child with a heart defect, or any history of heart disease, heart
surgery, rheumatic fever etc.
✓Immuno-compromised children
• malignant disease (e.g. leukaemia)
• neutropenic for considerable periods

Uniqueness of primary teeth pulp
• An increased number of accessory canals, foramina and porosity in pulpal
floors of primary teeth
• Primary root canals are more ribbon-like
• Fine, filamentous pulp system
• More difficult canal debridement
• Complete extirpation of pulp remnants almost impossible
• Increased potential of root perforation
• Root canal opening is several mm coronal to radiographic apex

Hibbard and Ireland, 1957
• multiple tortuous root canals in primary teeth
• various morphologic configurations in primary dentition -- mechanical
debridement and subsequent filling difficult
Moss et al, 1965
• connection b/w coronal pulpal floor & intra radicular area
Ringelstein and Seow (1989) confirmed findings of Moss et al.
• 42% of 75 extracted prim molars had foramina within furcation area
• no differences b/w prim 1st & 2nd molars
• many foramina on prim 2nd molars located on root surfaces

Evaluation of Treatment Prognosis before Pulp Therapy
• Tooth favorable to therapy
• Extraction & space management
• Pt. & parent cooperation
• Maintenance of oral health & hygiene

Types Of Pulpectomy
Single visit (Gould 1970)
Multiple visit (Gould & Starkey 1980)
Partial pulpectomy
Complete pulpectomy

Historical Perspective
• Sweet (1930) – 4 to 5 step technique using formocresol for the treatment
of pulpless teeth without fistula.
• Rabinowitz(1953) - treated nonvital primary teeth with a 2-3 day
application of FC, followed by precipitation with silver nitrate and a sealer
of ZOE into canals.
• Long procedure-avg. 5 visits for teeth without periradicular involvement
and avg. 7 visits for teeth with periradicular involvement.
• Hobson(1970)- canals not debrided.
Used breechwood creosote for 2 weeks followed by filling pulp chamber
with ZOE.

• Lewis & law(1973) First visit- canals medicated with eugenol, camphorated
parachlorophenol or FC.
Second visit- canals debrided and filled with ZOE or iodoform crystals
• Gould(1970) – One appointment technique
camphorated parachlorophenol placed in chamber for 5 min followed by
debridement of canal and pressing ZOE in prepared canals.
• Starkey(1980)
Multi-appointment for teeth with necrotic pulps and periradicular
involvement

Steps in pulpectomy
Access opening in primary teeth

General principles for the preparation of the access cavity:
There are three phases in the preparation of the access cavity:
• Penetration,
• Enlarging,
• Finishing.

Deciduous Incisors
• Pulp chamber-- fan shaped
• Relatively wider than permanent incisor
• extends further incisally
• Pulp horns– less pointed
• Wedge shaped pulp chamber

• Root canal– wide and splays out more
• Wider apical cross section
• Not clearly defined apical constriction
• Root canal widest labiolingually
• The apical third of root is perforated by many accessory canals

Deciduous Canine
• Pulp chamber– single pulp horn
• No obvious morphological border between pulp chamber and root canal, so
entire pulp cavity tapers evenly from the root apex
• Flattened root canal mesial and distally
• The root is longer than any other deciduous tooth
• Apical third, curves distally
• Root canal proportionally longer than crown height

Deciduous Molars
• Pulp chamber– relatively large to external dimension of the crown.
• The distance between pulp horn and enamel is sometimes as little as 2 mm
• Same number of pulp horns as cusps
• Root canals – irregular
• Ribbon like
• Root furcation is very close to the level of cemento-enamel junction

Maxillary molars
• Primary maxillary molars may have two to four roots, with the three-
rooted variant being the most common
• Fusion of the palatal and distobuccal roots occurs in approximately one-
third of the primary maxillary ﬁrst molars and occasionally in the primary
maxillary second molars

Second primary maxillary molars
• Second primary maxillary molars have three roots, and some exhibit fusion
between the DB and palatal roots, with the palatal root being the longest,
followed by the MB one.
• The DB root is the shortest and roundest of the three roots. Second
primary maxillary molars have either three canals (70 %) or four canals (30
%)

Mandibular first molars
• Mandibular first molars have normally two
roots;
• both are wider in the buccal-lingual
dimension, narrower mesiodistally, and
often grooved .
• Mandibular first molars have either three
canals (80 %) or four canals (20 %),
• the mesial roots usually have two root
canals, and the distal root has one or two
canals .
• Mean root canal length of first mandibular
molar: mesiobuccal 16.4 mm, mesiolingual
14.2 mm, distobuccal 13.1 mm, and
distolingual 12.7 mm

Mandibular second molars
• Mandibular second molars have normally two roots, mesial and distal, and
four canals (Fig. 6.4a, b) .
• Mean root canal length of second mandibular molar: mesiobuccal 15.8
mm, mesiolingual 14.4 mm, distobuccal 14.9 mm, and distolingual 14.9
mm

Primary Tooth Root Canal Physiology and Anomalies
• Roots of the primary teeth will begin to resorb as soon as the root length is
completed. This resorption causes the position of the apical foramen to
change continually.
• Because of accessory canals, interradicular bone lesion in inﬂamed primary
molars can be found anywhere along the root and especially in the
furcation area.
Ahmed HMA. Anatomical challenges, electronic working length determination and current developments in root canal preparation of
primary molar teeth. Int Endod J. 2013;46(11):1011–22.
Kramer PF, Faraco Júnior IM, Meira R. A SEM investigation of accessory foramina in the furcation areas of primary molars. J Clin
Pediatr Dent. 2003;27(2):157–61.

• Other root canal anomalies that should also be taken into consideration
include,
✓taurodontism,
✓a tooth with an enlarged pulp chamber
✓apical displacement of the pulpal floor
✓no constriction at the level of the cementoenamel junction as
characteristic features
✓C-shaped canal orifice
• but as they do not require modification of the pulpectomy technique, this
entity would not be dealt with separately.
Ahmed HMA. Anatomical challenges, electronic working length determination and current developments in root canal preparation of
primary molar teeth. Int Endod J. 2013;46(11):1011–22.

Histologic Considerations
• No difference between the pulp tissue, with an exception of the presence
of cap-like zone of reticular and collagenous fibers in the primary coronal
pulp
• Different pulp responses due to anatomic differences
• Enlarged apical foramen
• Abundant blood supply leads to more typical inflammatory response
• Primary teeth are less sensitive to pain due to difference in number and
distribution of nerves
John I de Ingle, Leif K. Bakland. Endodontics . 5th edition.

• Bernick (1959) -- found differences in the final distribution of pulp nerve
fibers.
• Rapp et al (1967) stated that primary teeth nerve density was lesser.
permanent teeth
the fibers terminate mainly
among the odontoblasts
and even beyond the
predentin.
primary teeth
pulp nerve fibers pass to the
odontoblastic area, where
they terminate as free nerve
endings.
Bernick S. Innervation of the teeth and periodontium. Dent Clin North Am 1959; p.503.
Rapp R, et al.. The distribution of nerves in human primary teeth. Anat Rec 1967;159:89.

ZOREMCHHINGI et al (2005)
• The mesial root canals of the mandibular molars and the mesiobuccal root
canals of the maxillary molars--greater variations
• a ribbon-shaped root canal system and the apical portion is less constricted
• Most of the variations -- buccolingual dimension which would not be
detected in clinical radiographic examination.
• The length of the roots are more variable in the maxillary molars but in the
mandibular molars the distal root is invariably longer than the mesial root
ZOREMCHHINGI., JOSEPH T. VARMA B. MUNGARA J. A study of root canal morphology of
human primary molars using computerised tomography: An in vitro study. J Indian Soc Pedo
Prev Dent - 2005

Lu Tang. 2011
• Root canal curvature--risk factors in root canal preparation
• When the degree of curvature increased, the success rate of working length
accessibility significantly decreased.
Lu Tang, Tuo-qi Sun, Xiao-jie Gao1, Xue-dong Zhou, Ding-ming Huang. Tooth anatomy risk
factors influencing root canal working length accessibility. Int J Oral Sci (2011) 3: 135-140.

Vivek Gaurav 2013
• More gradual tapering of the root canals-- maxillary incisors compared to
mandibular incisors.
• The roots of mandibular incisors- more angulation
• Mandibular incisors -- bifurcation of the root canal at the middle-third
(13% ).
Vivek Gaurav, Nikhil Srivastava, Vivek Rana, Vivek Kumar Adlakha. A study of root canal
morphology of human primary incisors and molars using cone beam computerized
tomography: An in vitro study. J of Ind Soc of Ped and Prevent Dent| .2013;31

• Palatal root of the maxillary molar --longest
• distobuccal root -- shortest.
• In mandibular molars, the mesial root -- longer than distal root.
• The mesial root of primary mandibular molars-- more divergent than distal
root
• distobuccal root of primary maxillary molar-- more divergence than other
two roots

• accessory canals, lateral canals, and apical ramifications of the pulp--10-
20%
• The maxillary primary molars-- two to five canals, the palatal root usually
rounder and longer than the two facial roots.

INDICATIONS
• Large carious exposure with frank involvement of radicular pulp but without any
periapical changes.
• Teeth with inflammation extending beyond the coronal pulp.
• Teeth with hemorrhage from amputated root stumps that is dark red, slowly
oozing and uncontrollable.
76

procedure
La and rubber dam
isolation
Diagnostic file
radiograph is not
needed to assess
root length:kennedy
Accessible radicular
pulp to be removed
After filing canals
should be irrigated
many times(atleast
10 flushings are
recommended)
with saline or
chloramine
followed by drying
with paper points
A small pleget of
cotton wool moist
with formocresol
placed in pulp
chamber for 3 min
Canals are filled
with a slurry
,medium cream
consistency of pure
zinc oxide paste
Single visit pulpectomy

Multi visit (Gould short term :1972 & Starkey:long term 1973)
• Indications(Paterson and Curzon 1992)
non vital
abscess
chronic sinus
teeth with necrotic pulp and periapical involvement
Fundamentals of pediatric dentistry. Richard J mathewson, Robert E primosch.3rd edition. Quintessence publishing co.

If the tooth is mobile ,if swelling
or a fistula is present or if pus is
present in canals then only light
instrumentation of canals is
recommended at first visit
drainage of pus
After 48-72 hours further
instrumentation of canals
(Paterson and Curzon 1992)
Rubber dam can be omitted in
cases of swelling and cellulitis
Between appointments
antibacterial drug in the pulp
chamber is sealed
A smooth broach should be used
to perforate the apices if
possible and the tooth to be left
open for longer than 24 hours.
then formocresol soaked cotton
pellet to be placed
Appointments should be 7-10
days apart

PARTIAL PULPECTOMY
• Indications:
• A partial pulpectomy may be performed on primary teeth when coronal pulp tissue and the tissue
entering the pulp canals are vital but show clinical evidence of hyperemia
• The tooth may or may not have a history of painful pulpitis but the contents of root canals should
be no radiographic evidence of thickened pdl or a radicular disease
J DEAN,D AVERY,R MC DONALDS,DENTISTRY FOR CHILD AND ADOLESCENT,10 TH ED

PROCEDURE
REMOVAL OF CORONAL
PULP
PULP FILAMENTS FROM
ROOT CANALS ARE
REMOVED WITH A FINE
BARBED
BROACH,CONSIDERABLE
HAEMORRHAGE WILL
OCCUR
A H FILE WILL BE HELPFUL
IN THE REMOVAL OF
REMNANTS OF THE PULP
TISSUE
A SYRINGE :3%H202
FOLLOWED BY SODIUM
HYPOCHLORITE,CANALS
TO BE DRIED WITH PAPER
POINTS
MIXTURE OF
UNREINFORCED
ZINCOXIDE
EUGENOLPASTE :PAPER
POINTS
SMALL KERR FILES MAY BE
USED TO FILE THE PASTE
INTO THE WALLS,
ROOT CANAL PLUGGERS
MAY BE USED TO
CONDENSE THE FILLING
MATERIALS INTO THE
CANALS

COMPLETE PULPECTOMY:STARKEY
RUBBER DAM AND LA
A PELLET MOISTENED
WITH CAMPHORATED
MONO CHLOROPHENOL
OR 1:5 CONCENTRATION
OF BUCKLEY ‘S
FORMOCRESOL ,WITH
EXCESS MOISTURE
BLOTTED SHOULD BE
PLACED IN THE PULP
CHAMBER
SECOND
APPOINTMENT:IF TOOTH
IS
ASYMPTOMATIC:PARTIAL
PULPECTOMY+APEX OF
EACH ROOT SHOULD BE
PENETRATED SLIGHTLY
WITH SMALLEST
DIAMETER
A treatment pellet should again
be placed in pulp chamber and
the seal completed with zinc
oxide eugenol
IF ASYMPTOMATIC THEN
OBTURATE

Pulp Extirpation
• Barb broaches , H-file
• Because of the bizzare anatomy of root canals the use of barbed broaches as in
conventional endodontics may be unsuccessful.
H-file ….why?
• To aid in access to the canals, H- files may be used to flair the canal orifices.
• Because H- files quickly open the canal orifice and eliminate pulp tissue, they must be
used with caution.
• Instrumentation with H-files is always directed toward the areas of the greatest bulk and
away from the furcation area to prevent stripping and perforation of the furcal position
of the thin root canal system.
A. Ashwatha Pratha and Ganesh JeevanandanInstrumentation techniques for pulpectomy in primary teeth - A review Drug
Invention Today | Vol 10 • Special Issue 2 • 20183144

• In comparison of the two hand files, H-files have shown better obturation quality as
compared to K-files. This can be attributed to the higher cutting efficiency of H-file due to the
triangular cross-section as compared to K-files.
Glickman GN, Koch KA. 21st-century endodontics. J Am Dent Assoc 2000;131 Suppl: 39S-46S.

• H files no 15 or 20 are strongly recommended since they remove hard tissue only on
withdrawal, which prevents pushing through the materials
• Maximum enlargement upto 30 k size file is recommended
• Each canal should be enlarged upto 3 to 4 size larger

Rotary in pediatric endodontics
• Advantage
a) Fast and simple
b) Short treatment time
c) Less appointments
d) Effective debridement of root canal without weakening tooth structure
e) Easy restore to maintain function of tooth
Farhin,k rotary instruments in pediatrics, Int journ of preventive and clinical research,2014

Disadvantages of rotary in primary teeth
• Primary dentin is softer and less dense than that of the permanent teeth and the roots
are shorter, thinner, and more curved.
• Root tip resorption is often undetectable. The root canal system is characterized by a
ribbon shaped root morphology (Finn, 1973).
S. George et al; Rotary endodontics in primary teeth 13; The Saudi Dental Journal (2016) 28, 12–17.

• The use NiTi rotary files in primary root canal was first described by Barr at al.
• The development of nickel titanium alloys and the possibility of changing the traditional
design and taper have allowed use of rotary instruments in endodontics.
• Their ability to rotate on their own axes in the root canal without any risk or damage to
the original anatomy is very important.
Farhin,k rotary instruments in pediatrics, Int journ of preventive and clinical research,2014

• Care to be taken
➢ Not to overinstrument as perforations can readily occur in the thin dentinal walls.
➢ Apical overextension of the NiTi can result in an enlarged apical foramen and cause an
overfill of pulpectomy paste.
Anna B. Fuks, Marcio Guelmann & Ari Kupietzky . Current Developments in Pulp Therapy for Primary Teeth.Endodontic
Topics 2012, 23, 50–72
✓ Barr ES et al (2000)
More effective in debriding uneven walls Provide consistently uniform
, predictable fill

Disadvantages:
1. Cost of the low-speed, constant-torque handpiece
2. Increased cost of Ni-Ti
3. Learning the technique
Advantages:
1. Tissue and debris are more easily and quickly
removed
2. The nickel-titanium files are flexible, allowing
easy access to all canals
3. Prepared canals are funnel shaped, resulting in
a more predictable uniform paste fill .
4.Faster than hand files

Kedo-S pediatric rotary file system consists of …..
• 3 NiTi rotary files with a total length of 16 mm.
• The working length of the file is 12 mm with a gradual taper
Reason = rotary system uses a progressively increasing taper.

Conclusion= Rotary NiTi files were as efficient as conventional hand
instruments in significantly reducing the root canal microflora.

Conclusion= The use of rotary instrumentation in primary teeth results in
marked reduction in the instrumentation time and improves the quality of
obturation.

• Methods of working length determination
RADIOGRAPHIC METHODS
Conventional method
Ingle method
Grossman method
Digital radiography
Xeroradiography
Radiovisiography
Tomography
NON RADIOGRAPHIC METHODS
Tactile sense
Paper point
Apical PDL sensitivity
Apex locators
✓ Working length determination is an extremely relevant factor for the success of root canal
treatments
Koruyucu M, et al. (2018) Comparison of root canal length measurement methods in primary teeth. Den$stry
3000. 1:a001 doi:10.5195/d3000.2018.83

• The working length should be 1-2 mm short of the radiographic apex ideally.
• If obvious signs of root resorption are present, it may be necessary to further shorten the working
length by an additional 1-2 mm in order to avoid overextension of the instruments into the
periapical tissues.
• Once the working length has been established, the canals are thoroughly cleaned.
• If hemorrhage is encountered after the pulp tissue has been removed, this is an indication that
root resorption likely has occurred and the working length should be shortened 2-3 mm from the
radiographic apex.
LTC Albert C. Goerig, DDS, MS Joe H. Camp, DDS, MSD Root canal treatment in primary- teeth: a review
PEDIATRIC DENISTRY: Volume 5, Number 1

• Proper detection of the working length is very important before pulpectomy in primary teeth.
Due to limitations of radiographic interpretation and high possibility of over-instrumentation of
the unevenly resorbed roots and subsequent overfilling, the use of electronic apex locators is
recommended regardless of the stage of root resorption.
Koruyucu M, et al. (2018) Comparison of root canal length measurement methods in primary teeth. Den$stry
3000. 1:a001 doi:10.5195/d3000.2018.83
✓ Apex locator was more likely to miscalculate root length in primary molars with
root resorption than direct canal measurement, yet Root ZX (Morita, USA) type
apex locator calculated accurately in cases in which root resorption was less
than one third of root length in primary molar teeth (Angwaravong O,
Panitvisai P (2009)

Conclusion= Apex locator eliminates the need for an additional radiograph during
pulpectomy procedure thereby reducing the ionizing radiation to the child patient as well as
for operator.
The result for this study from conventional r/g to apex locator gives same result.

• The use of apex locators in primary teeth has however not gained much popularity.
• The measurements appear to be less accurate when the apical foramen is immature or large,
which is often the case in primary teeth as they constantly undergo physiologic root resorption
Iyer Satishkumar Krishnan and Sheela Sreedharan A comparative evaluation of electronic and radiographic
determination of root canal length in primary teeth: An in vitro study Contemp Clin Dent. 2012 Oct-Dec; 3(4): 416–
420

IRRIGATION
Rationale for using irrigating solutions
• success of root canal therapy in primary teeth is determined by thorough removal of debris and
necrotic tissue.
• Due to the presence of deltas and fins in the root canal system of the primary teeth complete
elimination of bacteria by cleaning with endodontic instrument is impossible, this is where
adjunctive use of root canal irrigants along with mechanical instrumentation comes in.
• The currently used irrigants can be grouped into anti-microbial and decalcifying agents or their
combinations.
• Two or more irrigants in a specific sequence can tribute in a successful treatment outcome as no
single irrigation solution is regarded optimal
Nilotpol Kashyap., et al. “Irrigating Solutions in Pediatric Dentistry: A Big Deal in Little Teeth”. EC Dental Science
18.7 (2019): 1620-1626.

Chlorine releasing agents
potassium hypochlorite
sodium hypochlorite
II. Oxidizing agents
Hydrogen peroxide
Urea peroxide
Glyoxide
III. CHELATING AGENTS
EDTA
EDTAC
RC-Prep
IV. ORGANIC ACIDS
Citric acid
Maleic acid
Tannic acid
lactic acid
V. Inorganic acids
H2SO4 50%
HCL 30%
NITRIC ACID
VI. Detergents
Zephiran chloride
Endoquil
VII. Others
Chlorhexidine
Glutaraldehyde
Bis- dequalinium acetate
Antibiotics
MTAD
Carisolv
Electrochemically activated water
Oxidative potential water
Propolis
Ozone
Photodynamic therapy
Lasers
Electronic sterilization
VIII.HERBAL IRRIGANTS
ALOE VERA
OTHERS

• Kopel 1976
• Debridement in primary teeth- more dependent on chemical than mechanical means
• Braham Morris
• Primary molars –hourglass in shape
• Instrument + irrigation requirement
The ideal requisites of a root canal irrigant as given by Zehnder are:
1. Broad antimicrobial spectrum
2. High efficacy against anaerobic and facultative microorganisms organized in biofilms
3. Ability to dissolve necrotic pulp tissue remnants
4. Ability to inactivate endotoxin
5. Ability to prevent the formation of a smear layer during instrumentation or to dissolve the
latter once it has formed.
6. Systemically nontoxic when they come in contact with vital tissues, noncaustic to periodontal
tissues, and with little potential to cause an anaphylactic reaction.

Normal Saline
• universally accepted as the
• most common irrigating solution in all endodontic and surgical procedures.
• no side effects, even if pushed into the periapical tissues.
• However, saline should not be the only solution to be used as an irrigant, it is preferably used in
combination with or used in between irrigations with other solutions like sodium hypochlorite.
Sajeela Ismail, Amith Adyanthaya and Natta Sreelakshmi Intracanal irrigants in pediatric endodontics: A review Intracanal
irrigants in pediatric endodontics: A review

Sodium Hypochloride
• Effective hemostatic agent
• Helps to dissolve organic material
• Not toxic to pulpal tissues and does not interfere with pulpal healing (Fuks 2000, Nakornchai et al. 2005)
• 5.25% Ability to oxidize, hydrolyze and to some extent, osmotically draw fluids out of tissues (Pashley et al.
1985).
• A 5 % solution of sodium hypochlorite has excellent solvent action and is dilute enough to cause mild
irritation when contacting periapical tissue(Schilder and Amsterdam ,1959)
• It can be used in a small (15 ml) syringe fitted with a 25 gauge 1 ¼ in(32 mm)provided the needle fits loosely
in the canal.

Mechanism of action
NaOCl hypochlorous acid + hypochlorite ion
antimicrobial activity
1.penetration into bacterial cell wall
2. chemical combination with the protoplasm of the
bacterial cell wall and disruption of DNA synthesis

Drawbacks :-
• Cytotoxicity and caustic effects
• Inorganic component of smear layer is removed partially
• Unpleasant taste
• Must be kept in cool dry place , away from sunlight
✓ Must be used Judiciously and with great caution to prevent it from reaching the
periapex where it can elicit a severe inflammatory reactions
(Pashley et al. 1985, Fuks 2000, Mehdipour et al. 2007, AAPD guidelines)
✓ A study done by HARIHARAN et al to compare the efficacy of saline and NaOCl in its
ability to remove smear layer. Results showed that NaOCl was more effective than
Saline.
Ramachandra JA, Nihal NK, Nagarathna C, Vora MS. Root Canal Irrigants in Primary Teeth. World J
Dent 2015;6(3):229-234

• A 1% concentration of NaOCl provides sufficient tissue
dissolution and antimicrobial effect,
• but the concentration used has been as high as 5.25% because of enhanced anti-
microbial activity (Yesilsoy et al. 1995).
• As the concentration used rises so does its toxicity.
• Numerous reports have described clinical complications because of the improper use of
NaOCl
NaOCl toxicity

When it comes into contact with vital tissue, it causes
✓ haemolysis,
✓ Ulceration
✓ inhibits neutrophil migration
✓ damages endothelial and fibroblast cells (Gatot et al.1991).

Injection of sodium hypochlorite beyond the apical foramen- NaOCL Accidents
• extreme pressure during irrigation or binding of the irrigation needle tip
in the root canal which results in contact of large volumes of the irrigant
to the apical tissues.
• If this occurs, the excellent tissue-dissolving capability of sodium
hypochlorite will lead to tissue necrosis.
Symptoms
Pain
Immediate severe pain ( 2-6 minutes)
Edema
Immediate oedema of neighbouring soft tissues
Possible extension of oedema over the injured half side of the face, upper lip,
infraorbital region
Bleeding
Profuse bleeding from the root canal
Profuse interstitial bleeding with haemorrhage of the skin and mucosa (ecchymosis)

Management
• remain calm
• inform patient on cause and severity of complication
• Immediate irrigation with normal saline to dilute the NaOCl inorder to reduce the soft tissue
irritation.
Pain control
• Immediate relief of acute pain- local anaesthesia nerve block
• Analgesics
In severe cases
referral to a hospital

• Antibiotics:
• Antihistamine:
• Corticosteroids:
For reduction of swelling
• Extra oral cold compresses for the first 6 hrs
• warm compresses and frequent warm mouthrinses to be done after that.
• Most patients recover within 1-2 weeks although some cases of long term
paresthesia and scarring have been reported.
✓ Further endodontic therapy
with sterile saline or chlorhexidine as root canal irrigants

Hydrogen peroxide
• It is being used in dentistry in concentrations varying from 1% to 30%.
• H2O2 creates effervescence which facilitates debris removal, acts as an oxidizing agent and is
capable of denaturing bacterial proteins and DNA.
• But in higher concentrations, it is not well tolerated and has the potential of causing cervical
resorption

Chlorhexidine Gluconate (CHX)
• Chlorhexidine 2% is also commonly used as root canal irrigant, but it completely lacks tissue
dissolving capability.
• CHX antimicrobial activity is pH dependent, with the optimal range being 5.5–0.7.
• 2% CHX is significantly effective against root canal pathogens like Actinomyces israelii and
Enterococcus faecalis
the antimicrobial activity of two forms of CHX (gel and liquid) of three different concentrations (0.2%,
1%, and 2%) found that the 2% gel and 2% liquid formulations of CHX eliminated Staphylococcus aureus
and Candida albicans in about 15 seconds, whereas the gel formulation killed E faecalis within 1 minute.
(Gomes BP, Vianna ME, 2001)

• White et al. reported the substantivity of 2% CHX solution to last about 72 hours
• Khademi et al. stated that a 5 minute application of 2% CHX solution induced substantivity for up
to 4 weeks
• Rosenthal et al found that after a 10minute application the substantivity was up to 12 weeks.
Antimicrobial substantivity depends on the number of chlorhexidine molecules available for
interaction with dentine

EDTA (Ethylenediamine tetraacetic acid)
• Most commonly used as 17% neutralized solution, EDTA is a chelating agent used for the removal
of the inorganic portion of the smear layer.
• Continuous rinse with 5 ml of 17% EDTA, as a final rinse for 3 min efficiently removes the smear
layer from root canal walls.
• EDTA reacts with the calcium ions in dentine and forms soluble calcium chelates. Hence, exposure
for longer duration can cause excessive removal of both peritubular and intratubular dentin.
• It was reported that EDTA when used as a root canal irrigant in primary teeth, it removed the
smear layer but adversely affected the dentinal tubules.

MTAD (Mixture of tetracycline isomer, acid and detergent)
• Torabinejad et al. developed an irrigant with combined chelating and antibacterial properties.
MTAD is a mixture of 3% doxycycline, 4.25% citric acid, and detergent
• In this formulation, the citric acid may serve to remove the smear layer, allowing doxycycline to
enter the dentinal tubules and exert an antibacterial effect.
• The most recommended protocol for clinical use of MTAD advises an initial irrigation for 20
minute with 1.3% NaOCl, followed by a 5-minute final rinse with MTAD
• However the use of MTAD in primary teeth is limited because of chance of discoloration in
permanent buds present below. However, its use in young permanent teeth may not be
controversial (Nara A, Chandra DP, Anandakrishna L, Dhananjaya G. Comparative evaluation of antimicrobial efficacy of MTAD, 3%
NaOCl and propolis against E. Faecalis. Int J Clinic Ped Dent 2010 Jan-Apr;3(1):21-25.)

Carisolv
• Contain 0.5% sod. Hypo chloride along with amino acids.
• The hypothesis was that this agent can remove smear layer from root canal system when used as
an irrigant.

Tetraclean
• Tertaclean is a mixture of doxycycline hyclate (at a lower concentration than in MTAD), an acid
and a detergent.
• It is recommended to be used as a final rinse after root canal preparation.
• It contains doxycycline (50 mg per 5 ml) with polypropylene glycol (a surfactant) citric acid and
cetrimide.
• It is capable of eliminating all bacteria and smear layer from the root canal system when used as a
final rinse.

Electrochemically activated solutions
• A mixture of tap water in low concentrated salt solution forms the electrochemically activated
solutions.
• This results in the synthesis of anolyte and catholyte.
• The oxidative properties of anolyte exhibit antimicrobial activity against bacterias, viruses, fungus
and protozoa.
• The solution is also known as superoxidized water or oxidative potential water. Due to various
advantages such as removal of debris and smear layer as well as having non-toxic properties, it
can be used as potential root canal irrigants

Aqueous Ozone
• new generations of the disinfectant and a powerful oxidizing agent used to eliminate bacteria in
root canals
• antimicrobial efficacy against resistant pathogens by neutralizing them or preventing their growth
• Even at as low concentrations as 0.1ppm ozone is capable of deactivating bacterial cells including
their spores.
• Advantageous= properties of aqueous ozone is its nontoxicity to oral cells.
• disadvantage = aqueous ozone is its unstable concentration in a long time.

We should carefully choose irrigating solutions due to possible chemical interactions among
different irrigants.
Intermediate solutions such as saline or sterile distilled water, followed by careful drying, can
prevent the formation of toxic interactions
Reaction of sodium hypochlorite with EDTA
EDTA is used at concentration of 15% - 17% which has a neutral or slightly alkaline pH.
At this pH sodium hypochlorite reacts with EDTA which results in a decrease of free available
chlorine.
4HOCl = 2Cl2 + O2 + H2O
Clinical implication
Mixtures of EDTA and NaOCl which have a low pH results in the loss of free available e chlorine
which significantly reduces the ability of NaOCl to dissolve the organic tissue.
Basrani BR, Manek S, Sodhi RN, Fillery E, Manzur A. Interaction between sodium hypochlorite and chlorhexidine
gluconate. J Endod. 2007; 33:966-9

Reaction of sodium hypochlorite with chlorhexidine
• Chlorhexidine is a cationic bisguanide with broad spectrum antimicrobial properties against gram
positive bacteria.
• When NaOCl solution is mixed with chlorhexidine an orange brown precipitate is formed.
• This precipitation product has not been clearly identified but is similar to chloroguanide which is a
toxin.
Clinical implications
• The coloured precipitate can stain dentin. The precipitate can occlude dentinal tubules and canal
orifice, thus lowering the efficacy of endodontic irrigant.

Ahmed: Pulpectomy procedures in primary molar teeth European Journal of General Dentistry | Vol 3 | Issue 1 | January-April 2014

Herbal irrigants
Triphala and green tea polyphenols
• Triphala is an ayurvedic formulation consisting of dried powdered fruits of 3 medicinal plants.
• Terminalia bellerica
• Terminalia chebula
• Emblica officinalis
• Triphala consist of fruits that are rich in citric acid, which may aid in the removal of smear layer.
• The polyphenols found in green tea are known as flavanols.
• Theses favanols have significant anti- oxidant, anti-cariogenic, anti- inflammatory, thermogenic,
probiotic and antimicrobial properties.
• Studies have shown that triphala and green tea when used as an irrigant had antimicrobial
activity.
. J Prabhakar., et al. “Evaluation of antimicrobial efficacy of herbal alternatives (triphala and green tea polyphenols), MTAD, and 5% sodium hypochlorite
against enterococcus faecalis biofilm formed on tooth substrate: an in vitro study”. Journal of Endodontics 36.1 ,2010

Miswak
• Miswak is derived from Salvadora persica which is mainly used as a chewing stick.
• Wolinsky and Sote, by isolation of the active ingredient of S. persica found at the limonoid had a
great antimicrobial activity against gram positive and gram negative bacterias.
• In vivo studies have found that 10% to 20% extract of miswak was an effective antifungal and
antibacterial agent when used as an irrigant in the endodontic treatment of teeth with necrotic
pulp against C. albicans and E fecalis.
Poonam Shingare and Vishwas Chaugle. “Comparative evaluation of antimicrobial activity of miswak, propolis, sodium hypochlorite and saline as
root canal irrigants by microbial culturing and quantification in chronically exposed primary teeth”. Germs 1.1 (2011): 12-21.18

German Chamomile and Tea tree oil
• German chamomile is a medicinal plant known for the anti-inflammatory, antimicrobial,
antisporic and sedative properties.
• An SEM study done with German Chamomile extract and tea tree oil found that the smear layer
removing efficacy of German chamomile and tea tree oil to be superior to NaOCl and inferior to
EDTA.
Lahijani MS., et al. “The Effect of german chamomile (Marticaria Recutitia L.) extract and tea tree (Melaleuca Alternifolia L.) oil used as irrigants on removal
of smear layer: a scanning electron microscopy study”. International Endodontic Journal 39.3 (2006): 190195

AMAURY POZOS-GUILLEN1, Intracanal irrigants for pulpectomy in primary teeth: a systematic review and meta-analysis, 2016 BSPD, IAPD
and John Wiley & Sons

AMAURY POZOS-GUILLEN1, Intracanal irrigants for pulpectomy in primary teeth: a systematic review and meta-
analysis, 2016 BSPD, IAPD and John Wiley & Sons

AMAURY POZOS-GUILLEN1, Intracanal irrigants for pulpectomy in primary teeth: a systematic review and meta-analysis, 2016 BSPD, IAPD and John Wiley & Sons

Fernanda Barja-FidalgoA Systematic Review of Root Canal Filling Materials for Deciduous Teeth: Is There an Alternative for Zinc Oxide-EugenolInternational Scholarly Research Network ISRN Dentistry
Volume 2011, Article ID 367318, 7 pages doi:10.5402/2011/367318

Normal Saline Sodium Hypochloride Chlorhexidine Gluconate (CHX) EDTA (Ethylenediamine tetraacetic acid)
universally accepted as the
most common irrigating solution in all
endodontic and surgical procedures.
no side effects, even if pushed into the
periapical tissues.
However, saline should not be the only
solution to be used as an irrigant, it is
preferably used in combination with or
used in between irrigations with other
solutions like sodium hypochlorite.
Helps to dissolve organic material
Not toxic to pulpal tissues and does not
interfere with pulpal healing (Fuks 2000,
Nakornchai et al. 2005)
5.25% Ability to oxidize, hydrolyze and to
some extent, osmotically draw fluids out
of tissues (Pashley et al. 1985).
A 5 % solution of sodium hypochlorite
has excellent solvent action and is dilute
enough to cause mild irritation when
contacting periapical tissue(Schilder and
Amsterdam ,1959)
• Chlorhexidine 2% is also commonly
used as root canal irrigant, but it
completely lacks tissue dissolving
capability.
• CHX antimicrobial activity is pH
dependent, with the optimal range
being 5.5–0.7.
• 2% CHX is significantly effective
against root canal pathogens like
Actinomyces israelii and Enterococcus
faecalis
• Most commonly used as 17%
neutralized solution, EDTA is a
chelating agent used for the removal
of the inorganic portion of the smear
layer.
• Continuous rinse with 5 ml of 17%
EDTA, as a final rinse for 3 min
efficiently removes the smear layer
from root canal walls.
• EDTA reacts with the calcium ions in
dentine and forms soluble calcium
chelates. Hence, exposure for longer
duration can cause excessive removal
of both peritubular and intratubular
dentin.
• It was reported that EDTA when used
as a root canal irrigant in primary
teeth, it removed the smear layer but
adversely affected the dentinal
tubules.
Drawback
Cytotoxicity and caustic effects
Inorganic component of smear layer is
removed partially
Unpleasant taste
Must be kept in cool dry place , away
from sunlight

MTAD Carisolv Tetraclean Electrochemically activated
solutions
• Torabinejad et al. developed
an irrigant with combined
chelating and antibacterial
properties. MTAD is a mixture
of 3% doxycycline, 4.25% citric
acid, and detergent
• In this formulation, the citric
acid may serve to remove the
smear layer, allowing
doxycycline to enter the
dentinal tubules and exert an
antibacterial effect.
• The most recommended
protocol for clinical use of
MTAD advises an initial
irrigation for 20 minute with
1.3% NaOCl, followed by a 5-
minute final rinse with MTAD
• Contain 0.5% sod. Hypo
chloride along with amino
acids.
• The hypothesis was that this
agent can remove smear layer
from root canal system when
used as an irrigant.
• Tertaclean is a mixture of
doxycycline hyclate (at a lower
concentration than in MTAD),
an acid and a detergent.
• It is recommended to be used
as a final rinse after root canal
preparation.
• It contains doxycycline (50 mg
per 5 ml) with polypropylene
glycol (a surfactant) citric acid
and cetrimide.
• It is capable of eliminating all
bacteria and smear layer from
the root canal system when
used as a final rinse.
• new generations of the
disinfectant and a powerful
oxidizing agent used to
eliminate bacteria in root
canals
• antimicrobial efficacy against
resistant pathogens by
neutralizing them or
preventing their growth
• Even at as low concentrations
as 0.1ppm ozone is capable of
deactivating bacterial cells
including their spores.
• Advantageous= properties of
aqueous ozone is its
nontoxicity to oral cells.
• disadvantage = aqueous
ozone is its unstable
concentration in a long time.

Obturation
Ideal requirements of obturation material
• Resorption rate
• Disinfectant
• Beyond apex resorption
• Easy insertion and removal
• Non soluble
• No discolouration
• Radio opaque
• Harmless to tooth germ

Zinc oxide powder
Eugenol oil
Introduced by Bonastre (1837) and first
used by Chrisholm 1876.
Sweet (1930) first described the used of
ZnOE as root canal filling
material.
Advantage
✓ Excellent antibacterial & analgesic
effects (in lower concentrations)
✓ Radiopaque for good radiographic
visibility
✓ Easy to manipulate & fill in the canals
✓ Insoluble in tissue fluids
✓ Easily available
✓ Cost effective
✓ No tooth discolouration
Disadvantage
✓ Rate of resorption of material does
not coincide with that of root, is
slower in resorption
✓ When pushed beyond the canals, it
irritates the periapical tissue Is said to
show foreign body reaction in contact
with periapical tissue (necrosis of
bone & cementum)
✓ The excessive material is retained for
years even after exfoliation of the
primary tooth & is shown to harm the
permanent tooth bud, forms a
fibrous capsule & alters the path of
eruption
Zinc oxide eugenol

• Extruded zinc oxide eugenol cement
• Erasquin et al. 1967-- reported that canals overfilled with ZOE are not recommended because it
irritates the periapical tissues and causes necrosis of bone and cementum
• when ZOE extrudes, it develops a fibrous capsule that prevents resorption of the material (coll et
al 1985)
• a slow rate of resorption and has a tendency to be retained even after tooth exfoliation,
• unresorbed material has been found to cause deflection of the succedaneous teeth
Hashieh I A, Ponnmel L, Camps J . Concentration of 3. Eugenol apically released from ZnO E based
sealers. JOE 1999; 22(11): 713-715.

• Hashieh at al,
The amount of eugenol released in the periapical zone immediately after placement was10–4 and
falls to 10-6 after 24 hrs, reaching zero after one month. Within these concentrations eugenol is
said to have anti-inflammatory and analgesic properties that are very useful after a pulpectomy
procedure.
(Hashieh I A, Ponnmel L, Camps J . Concentration of 3. Eugenol apically released from ZnO E based sealers. JOE 1999; 22(11): 713-715.)
• Coll and Sadrian (1996) reported anterior cross-bite, palatal eruption, and ectopic eruption of
the succedaneous tooth following ZOE pulpectomy where fragments are left.

NAJJAR ET AL, A comparison of calcium hydroxide/iodoform paste and zinc oxide eugenol as root filling materials for pulpectomy in primary teeth: A systematic review and meta‐analysis Clin Exp Dent Res. 2019;5:294–310

Nalawade HS, Lele GS, Walimbe H. Outcome of zinc oxide eugenol paste as an obturating material in primary
teeth pulpectomy: A systematic review. J Dent Res Rev 2017;4:90-6.

Rajsheker S, Mallineni SK, Nuvvula S (2018) Obturating Materials Used for Pulpectomy in Primary Teeth- A Mini
Review. J Dent Craniofac Res Vol.3 No.1: 3.

Kri paste
Iodoform –80%
Camphor – 4.8%
Parachlorophenol – 2%
Menthol – 1.2%
Maisto paste
Zinc oxide –14gms
Iodo form –42gms
Thymol –2gm
Chlorophenol Camphor 3cc
Lanolin –0.5gms
IODOFORM BASED PASTES
✓ Tagger and Sarnat – used the mixture of ZnOE & iodoform paste as the root canal
filling material in 1984, but introduced by Maisto in 1967.
✓ Rifkin - KRI as a final filling material and as a medicament between visits in 1980.
✓ Garcia – Godoy (1987) – found no failure with KRI
Pediatric dentistry- Infanct through adoloscence.Casamassimo,Fields,Mctigue,Nowak.5th edition. Elsevier.Mosby

KRI PASTE
Iodoform
Relievespain
Potentdisinfectant
Menthol
Anodyne
Antispasmodic
antiseptic
Camphor
arrest the hemorrhage
Allays pain of wounded pulp ofteeth
Parachlorophenol
Disinfects root canal
Treating periapical infections
• Fuks AB et al in 2000 found that the success rates of 84% with KRI paste group verus
65% with ZOE group
• Overfills more successfull KRI paste 79% versus ZOE 41%. The excess paste will resorb
without causing any adverse side effects.

• Garcia Godoy (1987) found that KRI paste resorbs from the apical tissue in a week or two; it does
not set to a hard mass and can be inserted and removed easily.
(Garcia Godoy F. Evaluation of an iodoform paste in root canal therapy for infected primary teeth. JDC 1987; 54:30-34.)

METAPEX/VITAPEX
✓iodoform 40.4%,
✓calcium hydroxide 30.3%,
✓silicon 22.4%.
ADVANTAGES
• Has no toxic effects on the
permanent successor tooth
• Good antiseptic action
• Adheres well to the canal walls
• It does not set to a hard mass
• Resorption occurs at a slightly
faster rate then the roots,
complete resorption of the
excess paste is expected within
2-8 weeks.
• Ease of applicability of the
material
• Is radiopaque, so better
radiographic visibility
DISADVANTAGE
• Iodoform-based material
though resorbs if pushed
beyond the apex however
the rate of resorption is
faster than the roots.
• Causes discoloration of the
teeth.
• The rapid elimination of
iodoform by the organism
leaves behind empty spaces
inside the root canal, which may
undermine the success of the
endodontic therapy.
Resorption
has a tendency to get depleted
from the canals earlier than the
physiologic resorption of the roots
iodoform-based -- resorbs if
pushed beyond the apex however
the rate of resorption is faster
than the root.
Erasquin et al. 1967, -- iodoform is
irritating to the periapical tissues
and can cause cemental necrosis
NurkoC
,GarciaGodoyF
.
Evaluationof acalcium hydroxide/iodoform paste(Vitapex)in root canaltherapy for primary
teeth. J
ClinPediatr Dent.(1999).23:289–94.

Trairatvorakul C (2008)Vitapex appeared to resolve furcation pathology at a faster rate than zinc
oxide-eugenol at 6 months, while at 12 months, both materials yielded similar results
(Chawla HS, Mathur VP, Gauba K, Goyal A. A mixture of calcium hydroxide and zinc oxide
as a root canal filling material for primary teeth: a preliminary study. ISPPD. (2001). 19: 107–9).
•When extruded into furcal or apical areas, can either diffuse away or be resorbed in part by
macrophages in one or two weeks.
• Bone regeneration has been documented after using Vitapex.
•Easy delivery system
•Resorbs at a slightly faster rate than that of the roots.
Jung-wei Chen & Monserrat Jorden . Materials for primary tooth pulp treatment: the present and the future. Endodontic Topics 2012, 23, 41–49
Endodontics .John I de Ingle, Leif K. Bakland. 5th edition. B.C. Decker publishers

• Vitapex when extruded into furcal or apical areas, can either get diffused or resorbed by
macrophages, in as short a time as 1 or 2 weeks up to 2 to 3 months and causes no foreign body
reaction,
• success rate of 96% to 100% (Nurko et al 1999)
• Nurko et al.(1983) said that vitapex as success rate of 96 to 100% when extruded into furcal or
apical area.
• the use of iodine-based materials in contact with live tissues has no longer been indicated
because of their potential for causing toxic side-effects.
Sunitha B, K Pratej Kiran, Ravindar Puppala, Balaji Kethineni, Ravigna. Resorption of Extruded Obturating Material
in Primary Teeth. Indian Journal of Mednodent and Allied Sciences Vol. 2, No. 1, February 2014, pp- 64-67

Resorption
• has a tendency to get depleted from the canals earlier than the physiologic resorption of the
roots
• iodoform-based -- resorbs if pushed beyond the apex however the rate of resorption is faster
than the root.
• Erasquin et al. 1967, -- iodoform is irritating to the periapical tissues and can cause cemental
necrosis
• Easy resorption.
• the rapid elimination of iodoform by the organism leaves behind empty spaces inside the root
canal, which may undermine the success of the endodontic therapy
Sunitha B, K Pratej Kiran, Ravindar Puppala, Balaji Kethineni, Ravigna. Resorption of Extruded Obturating Material
in Primary Teeth. Indian Journal of Mednodent and Allied Sciences Vol. 2, No. 1, February 2014, pp- 64-67

Iodoform
Zinc Oxide (56.5%),
Calcium Hydroxide (1.07%),
Tri-iodomethane
Dibutilorthocresol (40.6%),
Barium Sulphate (1.63%)
Liquid Consisting Of Eugenol And
Paramonochlorophenol.
Advantage
• firmly adheres to the surface
of the root canals to provide a
good seal.
• broad spectrum of
antibacterial activity
• the ability to disinfect
dentinal tubules and difficult
to reach accessory canals that
cannot be disinfected or
cleansed mechanically
• when extruded extra-
radicularly, but does not wash
out intra-radicularly (Fuks et al
2002)
Types
Endoflas CF (free of chlorophenol)
Endoflas FS (with chlorophenol)
• Due to this endoflas cf was
developed which is free of
chlorophenol. Chlorophenol
was eliminated from endoflas
composition because it has
fixation effect which may
affect the osteoblast cells
Endoflas

• The material is hydrophilic and can be used in mildly humid canals. It firmly adheres to the
surface of the root canals to provide a good seal.
•Due to its broad spectrum of antibacterial activity, Endoflas has the ability to disinfect dentinal
tubules and difficult to reach accessory canals that cannot be disinfected or cleansed mechanically.
• Unlike other pastes, Endoflas only resorbs when extruded extra- radicularly, but does not wash
out intra-radicularly (Fuks et al 2002)
• Ramar & Murgara (2010) observed a much higher success rate with Endoflas (95%) compared to
other materials and also reported healing ability, bone regeneration characteristics and
resorption of excess Endoflas without washing within the roots.

•Antimicrobial efficacy of various materials according to this study can be summarized as follows:
• Endoflas > ZOE >Calcium hydroxide + Chlorhexidine > Calcium hydroxide + Iodoform
+Distilled water ~ Metapex > Saline.
(NAVIT S et al.Antimicrobial Efficacy of Contemporary Obturating Materials used in Primary Teeth- An
In-vitro Study.2016 Journal of Clinical and Diagnostic Research. 2016 Sep, Vol- 10(9): ZC09-ZC12)
Resorption of endoflas
✓ Fuks et al. 2002, Endoflas resorbed when over-extended periapically
✓ not resorb intraradicularly in their study
✓ bone regeneration
✓ resorption of excess Endoflas without washing within the roots

• Endoflas CF (free of chlorophenol)
• Endoflas FS (with chlorophenol)
• The clinical and radiographic success rate of endoflas CF paste (free of chlorophenol) was 87.5%
and 81.3% respectively after 12 months as similar as the radiographic success of endoflas FS (with
chlorophenol) in Fuks et al. study 2002 (83%), and Moskovitz et al. 2005 (79%).
• Radiolucent lesions following endodontic treatment of primary teeth were, may be due to the
filling material that contain phenol.
• Due to this endoflas cf was developed which is free of chlorophenol. Chlorophenol was
eliminated from endoflas composition because it has fixation effect which may affect the
osteoblast cells
Al-Ostwani AO, Al-Monaqel BM, Al-Tinawi MK. A clinical and radiographic study of four different root canal fillings
in primary molars. J Indian Soc Pedod Prev Dent 2016;34:55-9.

Author Comparing material Success rate ZOE SUCCESS RATE
(COMPARING
MATERIAL)
Anna fucks 2003 Endoflas - 70%
M. MORTAZAVI
2004
Vitapex 78·5% 100%
Trairatvorakul 2008 Vitapex 85% 89%
Saziye Sarı 2008 Sealpex - 92.3%
S Gupta 2011 Metapex 85.71% 90.48%
Achiraya Duanduan
2013
Vitapex- LSTR 84.6 % LSTR 89%
Ramer K 2013 Metapex, endoflas ZOE+ iodoform
84.7%
Metapex
90.5
Endoflas
95.1%
Nivedita Rewal 2014 Endoflas 83% 100%
Navit S et AL 2016 Endoflas > ZOE >Calcium hydroxide +
Chlorhexidine > Calcium hydroxide +
Iodoform +Distilled water ~ Metapex >
Saline.:ANTIMICROBIAL EFFICACY

• TECHNIQUES OF OBTURATION
• Endodontic pressure syringe
• Mechanical syringe
• Tuberculin syringe
• Incremental filling technique
• Lentulospiral technique
• Jiffy Tube
• The Reamer Technique
• The Insulin Syringe Technique
• NaviTip
• Bi-Directional Spiral
• Pastinject
Other techniques:
•Amalgam plugger- Nosonwitz 1960 & King 1984
•Paper points – Spedding 1973
•Plugging action with wet cotton pellet (ZOE of tooth paste
consistency) – Donnenberg 1974.

Endodontic pressure
syringe
•Developed by Greenberg
•Described by Spedding and Krakow in 1965.
•Consists of syringe barrel,threaded plunger,wrench and threaded needle.
•The 13 to 30 gauge needle which corresponds to the largest endodontic file can be used to instrument
the root canal.
Disadvantage
Difficulties in placing the rubber stop correctly
reinsert the syringe repeatedly
the paste, create voids, and thus decrease filling quality
time-consuming
Mechanical syringe Proposed by Greenberg in 1971.
• Syringe with 30 gauge needle.
• Cement pressed using continous pressure while withdrawing the needle.
• According to Ayland and Johnson 1987 ,mechanical syringe was a poor performer in both canal types
i.e. curved and straight canals.
Tuberculin syringe Arnold and Johnson 1987
• Standard 26 gauge, 3/8th inch needle
• The tuberculin syringe group had the worst results for the length of obturation among other
techniques used in a study conducted by Memarpour et al.2013
Drawback according to Memarpour et al.2013
• difficulty of separating the tip during injection, which results in the need to repeatedly replace the
needle. This may compromise optimal filling and increase the presence of voids in the paste.

Incremental filling technique Gould in 1972.
• Creamy mix of ZOE carried into canals, deposited with endodontic plugger in small
increaments.
• Length of the endodontic plugger equaled the predetermined root canal length minus 2 mm.
Additional increments of 2-mm blocks were added until the canal was filled to the cervical
area.
Drawback
• Placing the paste in a narrow, apically curved canal is more difficult than in a wider apical
preparation. Because the flexibility of endodontic pluggers is limited, the paste cannot be
placed in the full working length of narrow, curved canals.
Lentulospiral technique Kopel in 1970
• creamy mix of filling paste can be coated around the walls of the canals with lentulospiral or
the last used file(Duggal and Curzon 1994)
• The spiral root filler should be one size smaller than the last used file and cut half its length
with scissors
• Dipped into mixture and then introduced into the canal to its predetermined length and
rotated in the canal.
Jiffy Tube popularized by Rifficin in 1980.
• standardized mixture of ZOE is back-loaded into the tube.
• The tube tip is placed into the simulated canal orifice and the material expressed into the
canal with a downward squeezing motion until the orifice appears visibly filled.

Reamer Technique reamer coated with ZOE paste was inserted into the canal with clockwise rotation, accompanied by a
vibratory motion to allow the material to reach the apex, and then withdrawn from the canal, while
simultaneously continuing the clockwise rotary motion
• the process was repeated 5 to 7 times for each canal until the canal orifice appeared filled with the
paste.
• According to Priya Nagar et al showed that the obturation quality of both the reamer technique and
insulin syringe technique was found to be very closely related.
Insulin Syringe Technique described by Priya Nagar
• The needle is inserted into the canal and kept about 2mm short of apex.
• material is then pressed into the canal and while doing so the needle is retrieved from the canal
outwards while continuing to press the material inside.
Drawback
• optimum operator skills and proper material mix required
NaviTip • A thin and flexible metal tip was introduced viz., NaviTip (Ultradent), in the market to deliver root
canal sealer
• comes in different lengths and a rubber stop may be adjusted to it
• Guelmann et al assessed the quality of root canal filling by using three filling systems: syringe with
plastic needle (Vitapex), syringe with metal needle (NaviTip), and lentulo spiral.
• Conclusion= due to paste thickness, material could not be expressed via the NaviTip™ lumen.
• According to Mahtab Memarpour 2013, the best results in controlling paste extrusion from the apical
foramen and having the smallest void size and lowest number of voids.

Bi-Directional Spiral Pastinject
Dr. Barry Musikant
Advantage
minimal amount of obturating material will past the
apex.
specially designed paste carrier with flattened blades
Advantage
improves material placement into the root canal.
controlled coverage is achieved because the spirals at
the coronal end of the instrument spin the material
down the shaft towards the apex, while the spirals at
the apical end spin the material upward towards the
coronal end.
Grover et al, it was concluded that among
lentulospirals, bi-directional spiral, pastinject and
pressure syringe, the pastinject technique has proved
to be the most effective, yielding a higher number of
optimally filled canals and minimal voids, combined
with easier placement of the material into the canals.
Study
The study by Muskant et al. [1998] observed that the
bi-directional spiral prevented the apical extrusion of
the sealer from the root canals of permanent teeth.
Mahajan N, Bansal A.Various Obturation methods used in deciduous teeth. Int J Med and Dent Sci 2015; 4(1):708- 713.

Sigurdsson et al. 1992 The lentulo spiral—most effective instrument and
produce highest quality obturation
(Aylard and Johnson 1987 Endodontic pressure syringe and the lentulo spiral
were superior for filling straight canals while the
lentulo spiral was superior for the obturation of
curved canals
Aylard and Johnson 1987 Lentulo spiral-- best overall ZOE filling tool
Singh R, Chaudhary S 2015 Motor driven lentulo spiral technique demonstrate
more number of optimal fills with fewer voids
when compared to hand held lentulo spiral
technique and reamer
A Singh et al 2017 Endodontic pressure syringe system is the best
method
Khubchandani 2017 Lentulospiral produced the best results in terms of
length of obturation
Mahajan N, Bansal A.Various Obturation methods used in deciduous teeth. Int J Med and Dent Sci 2015; 4(1):708-
713.

Definition
It is a method to induce development of the root apex of an immature, pulpless tooth by formation of
osteocementum or other bone like tissue. (Grossman)
➢Defined as a method to induce a calcific barrier in a root with an open apex or the continued apical development
in an incomplete root in a tooth with necrotic pulp.
(American Association of Endodontists 2018-19)

An immature pulp is one where apex is open. The problems that come during treatment of an immature tooth
are:
• No hard tissue stop against with gutta percha can be packed.
• Obturation becomes difficult .
• Apisectomy is not possible as it may fracture the root apex.
open apex
Definition - Absence of sufficient root development to provide a conical
taper to the canal and is also referred to as blunderbuss canal.
S. Weine 1972

Causes of open apices
• caries with pulp involvement,
• extensive resorption of the mature apex as a result of orthodontic treatment,
• Periapical pathosis,
• Trauma causing necrosis
This open apex causes two major problems.
• The normal crown /root ratio is compromised and may cause mobility.
• It becomes difficult to achieve an apical seal with conventional root canal filling.
Types of open apices
1- non-blunderbuss
2- blunderbuss

• Non –blunderbuss:
❑ broad (cylinder shaped)
❑ tapered (convergent)
Blunderbuss:
❑ The apex is funnel shaped and -typically wider than the
coronal aspect of the canal.
Problems associated with immature apex
• Large open apices
• Thin dentinal walls
• Frequent periapical lesions
• Short roots
• Fracture of crown
“Blunderbuss” is referred to as the 18th century weapon which has a short and
wide barrel. It derives its origin from the Dutch word “DONDERBUS” which means
“thunder gun.”

Stages of root development Cvek 1972
I = < 1/2 root length,
II = 1/2 root length,
III = 2/3 root length,
IV = wide open apical foramen and nearly complete root
length and,
V = closed apical foramen and completed root development.
Importance = endodontic procedure selection most likely depends on the maturity of
the affected root
Plascencia H, Díaz M, Gascón G, Garduño S, Guerrero-Bobadilla C, Márquez-De Alba S, González-Barba G. Management of permanent teeth with
necrotic pulps and open apices according to the stage of root development. J Clin Exp Dent. 2017;9(11):e1329-39.

Diagnosis and case assessment
o Clinical assessment of pulp status, clinical & radiographic examination.
o Subjective symptoms
o Pain history – spontaneous, severe, long lasting
o Throbbing, tender to touch - pulpal necrosis with apical periodontitis or
acute abscess
o Swelling /sinus tract - indicates pulpal necrosis and acute or chronic abscess respectively
o Tenderness to percussion -inflammation in the periapical tissues.
T
reatment
Treatment is based on the vitality of the pulp.
• If the immature tooth has vital pulp, exhibiting reversible pulpitis, thenphysiological root
end development or apexogenesis is attempted.
• On the other hand if irreversible pulpitis is present or pulp is necrotic, then root end
closure or apexification is induced.

Pulp treatment procedure in young permanent teeth
(Vital pulp treatment) (Non vital pulp treatment)
Indirect pulp capping Pulpectomy
Direct pulp capping
Pulpotomy
Apexogenesis
Apexification
AAPD reference menual 2018-19

Apexogenesis Apexification
◼ It is physiologic process of root
development in vital infected
tooth
◼ Normal or pulp tissue with
minimal inflammation present:
completely - direct pulp capping
radicular portion – pulpotomy
◼ Normal root end development .
◼ It is inducing the development of root
apex in immature pulp less tooth by osteo
cementum or bone like material
◼ Indicated in irreversible pulpal necrosis
◼ Normal root development takes places
rarely. Calcific barrier is formed clinically
and radio graphically .
170

• ‘Root-End Closure’, introduced by Torabinejad in 2002.
Indication contraindication Objectives
• restorable immature tooth
with pulp necrosis.
• All vertical and unfavorable horizontal
root fractures.
• Veryshort roots
• Periodontal breakdown
• Induce root end closure
• No evidence of post treatment signs and symptoms
• No evidence of calcification
• No internal or external resorption
• No breakdown of periradicular supporting tissues
Uptal kumar das, Building the Barrier, A Comparison of Mineral Trioxide Aggregate and Calcium Hydroxide in Apical barrier technique:
Report of Three Cases , Int.J.Adv.Res.Biol.Sci.2014; 1(6):122-127

According to Morse et al.,(1983) various approaches :
Blunt end or rolled cone
(customizedcone)
Short filltechnique Periapical surgery (with /without
retrograde seal)
Apexification (apical closure
induction)
Filling the root canal with the large
(blunt) end of a gutta-pereha cone
or customized gutta-percha cones
with a sealer
Moodnick proposed removal of
the bulk of the necrotic tissue &
filling the root canal short of the
apex with gutta percha
Filling the root canal with gutta-
percha and sealer as well as
possible and then performing
periapical surgery with or without
a reverse seal.
I t would also be difficult to assess
the point of root development
radiographically because root
formation in the buccolingual
plane is less advanced than it is in
the mesiodistal plane.
However with an incomplete
obturation, microbes can be left
remaining within the apical part of
the root canal system & healing
may not take place or periapical
breakdown may occur later.
Drawback
• Relative to the already
shortened roots, further
reduction could result in an
inadequate crown to root
ratio.
• Surgery could be both
physically & psychologically
traumatic to the young
patient.
• Surgery would remove the
root sheath & prevent the
possibility of further root
development
Uptal kumar das, Building the Barrier, A Comparison of Mineral Trioxide Aggregate and Calcium Hydroxide in Apical barrier technique: Report of Three Cases ,

Apexification (apical closure induction)
• Materials to induce Apexification in teethwith immature apices
• Calcium hydroxide
• Ca(OH)2 for apexification in the pulpless tooth was first reported by Kaiser in 1964
• The technique was popularised by the work of Frank in 1966
The calcium hydroxide powder has been mixed with
• camphorated parachlorophcnol (CMCP),
• metacresyl acetate,
• Cresanol {a mixture of CMCP and metacresyl acetate),
• physiologic saline,
• Ringer's solution,
• distilled water, and
• anesthetic solution.
Although some of these materials appear to enhance the action of the Ca(OH)2 better than others, all
have been reported to stimulate apexification.
Other medicament
• Tricalcium phosphate
• Collagen calcium phosphate
• Mineral trioxide aggregate.
• Biodentine
• Bone morphogenic proteins
Uptal kumar das, Building the Barrier, A Comparison of Mineral Trioxide Aggregate and Calcium Hydroxide in Apical barrier technique:
Report of Three Cases , Int.J.Adv.Res.Biol.Sci.2014; 1(6):122-127

• Procedure
• Anesthetize and isolate
• Access is made
• Instrumentation
• Initial treatment length
• Acc to Torneck et al & Holland et al.,
• Primary aim- Enlargement
• Acc to Ingel – H files, circumferential filling
• If periapical abscess is present, over-
instrumentation with smaller f
iles (20-25) will
establish drainage.
• Ingle recommends that further treatment
should be done only when active lesion has
subsided.
Irrigation
• Sodiumhypochlorite
• Alternation with hydrogen peroxide -weine
• Subsequent appointments-sterile water orisotonic saline-Webber
Cohen’s pathway of pulp 12th edition

Drying of the canals
• Often difficult because of seepage
• Paper points are pre measured to working length
• An inverted coarse point is often desirable.
• In continuous seepage, a pre fitted point can be left in canal until calcium
hydroxide is placed
Techniques of calcium hydroxide placement:
Webbers technique
• Using amalgam carrierand endodontic pluggers.
• 3-4 increments of CH is placed with amalgam carries and pushed apicaly with a plugger.
Cohen’s pathway of pulp 12th edition

Successive increments is placed with amalgam carrier and pushed apicaly with larger plugger.
Care should be taken to see that material is in contact with periapical tissue.
Refilling procedure- Holland
• First recall is at 6 weeks
• Paste is diluted in canal.
Acc to Holland et al.,
• Removed 1-2mm short of the original working length
• Remaining powder on canal walls removed with largersize instruments.

Periodic recall:
• Apical development is monitored by comparison of pre-operative and post-operative radiographs. We look for:
• Formation of calcific bridge.
• Continued apical development
• Absence of internal resorption radiolucency
• Time to achieve apexification is 6 to 24 months (average 1year +/- 7 months).
• Patient is recalled after every 3 months for radiographic evidence of calcification
• The tooth is reentered and clinical verification is done by failure of small instrument to enter beyond apex after removal of Ca (oh) 2 pastes.
• Once verification is complete canal is obturated with G.P taking care of apical barrier.
Procedure to detect barrierformation
• Radiographic evaluation
• Paper point

• Mechanism of action of Ca(OH)2 to induce formation of a solid apical barrier
Protein denaturation
Cellular metabolism highly depends on enzymatic activities.
Enzymes in turn have optimum activity & stability in a narrow range of pH. The alkalization
provided by Ca(OH)2 through hydroxyl ions induces the breakdown of, ionic bonds that maintain
the tertiary structure of proteins.
This results in loss of biological activity of enzymes & disruption of cellular metabolism.
DNA damage Hydroxy ions react with bacterial DNA & induce the splitting of strands. Then genes are lost DNA
replication is inhibited & the cellular activity is deranged.
Carbon dioxide absorption It has been suggested that the ability of Ca(OH)2 to absorb CO2 may contribute to its antibacterial
activity.
Carbon dioxide is essential for many bacteria such as Capnocytophaga, Actinomyces.
So when Ca(OH)2 reacts with CO2 producing CaCO3 & water, the intracanal environment changes which
remains no more conducive for growth of such micro-organisms.
Apical barrier In addition to elimination of viable bacteria unaffected by biomechanical preparation of the root,
Ca(OH)2 acts as a physical barrier & kills remaining micro organism by withholding substrate for growth
& limiting space for multiplication.
Dissolution of Necrotic
material
Tissue solvent action of Ca(OH)2 paste was reported by Hasselgrea in 1988. Later Andersen et al in 1992,
reported that Ca(OH)2 paste could dissolve tissue faster that 2% NaOCI during initial 15 min but after 30
min, the dissolving efficiency decreased rapidly.
Siqueira Jr JF, Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: a critical review (Review). International Endodontic Journal,
32, 361±369, 1999

MECHANISM OF ACTION OF Ca(OH)2 TO INDUCE FORMATION OF A SOLID APICAL BARRIER
• The continuous absorption/depletion of Ca(OH)2 paste from the root canal suggests that it is continuously
used in the formation of the bridge. The mechanism by which Ca(OH)2 acts in the formation of the bridge is
still not fully understood.
• However, Holland described in vivo, a phenomenon when calcium carbonate crystals were produced by a
reaction between the carbon di-oxide in the pulp tissues and the calcium of the capping materials.
• Alkaline pH and calcium ions might play a part either separately or synergistically. The calcium required for
the apical bridge formation comes through the systemic route as demonstrated by Sciaky and Pisanty.
Pisanty and Sciaky using radiolabled Ca(OH)2.
• As the calcium ions from the calcium hydroxide dressing do not come from the calcium hydroxide but from
the bloodstream the mechanism of action of calcium hydroxide in induction of an apical barrier remains
controversial. Some of the postulated mechanisms of the osteoconductive effects of Ca(OH)2 are as follows:

1. Presence of high calcium concentration increase the activity of calcium dependent pyrophosphatase
• Mitchell and Shankwalker studied the osteogenic potential of calcium hydroxide when implanted into the
connective tissue of rats. They concluded that calcium hydroxide had a unique potential to induce formation
of heterotopic bone in this situation. Of 11 other materials used in comparative studies, only plaster of Paris
(calcium sulfate hemihydrate) and magnesium hydroxide demonstrated any osteogenic potential.
• Heithersay has postulated that calcium hydroxide may act by increasing the calcium concentration at the
precapillary sphincter, reducing the plasma flow. In addition, the calcium ion can affect the enzyme
pyrophosphatase, which is involved in collagen synthesis. Stimulation of this enzyme can facilitate repair
mechanisms.
2. Direct effect on the apical and periapical soft tissue
• Holland et al. have demonstrated that the reaction of the periapical tissues to calcium hydroxide is similar to
that of pulp tissue.
• Calcium hydroxide produces a multilayered necrosis with subjacent mineralization. Schroder and Granath
have postulated that the layer of firm necrosis generates a low-grade irritation of the underlying tissue
sufficient to produce a matrix that mineralizes. Calcium is attracted to the area and mineralization of newly
formed collagenous matrix is initiated from the calcified foci.
• Schroder and Granath showed that OH ions induced the development of a superficial necrotic layer acting as
a surface to which the pulpal cells gets attached, leading to bridge formation.

3. High pH, which may activate alkaline phosphatase activity
• It appears that the high pH of calcium hydroxide is an important factor in its ability to induce hard tissue
formation.
• Javelet et al , compared the ability of calcium hydroxide (pH 11.8) and calcium chloride (pH 4.4) to induce
formation of a hard tissue barrier in pulpless immature monkey teeth.
• Periapical repair and apical barrier formation occurred more readily in the presence of calcium hydroxide.
4. Antibacterial activity
• It has been demonstrated that apical barrier formation is more successful in the absence of microorganisms
and the antibacterial efficacy of calcium hydroxide has been established).
• The antimicrobial activity is related to the release of hydroxyl ions, which are highly oxidant and show
extreme reactivity. These ions cause damage to the bacterial cytoplasmic membrane, protein denaturation
and damage to bacterial DNA.

• Apexification requires the formation and maintenance of an apical calcified barrier, which consists of osteo-
cementum or other bone-like tissue.
• Under ideal conditions, residual pulp tissue and the odontoblastic layer may form a matrix, such that the
subsequent calcification can be guided by the reactivated epithelial cell rests of Malassez or non periapical
pluripotent cells within bone.
• Barrier formation also depends on the degree of inflammation and pulp necrosis, displacement at the time
of trauma, and number of calcium hydroxide dressings, which can complicate (or at least delay) treatment.
• Calcium hydroxide can induce healing conditions because of its antibacterial behavior.
• As a result of its high pH, the highly reactive hydroxyl ions produce damage to the bacterial cytoplasmic
membrane by denaturing protein and destroying lipoproteins, phospholipids, and unsaturated fatty acids.
• Consequently, these actions lead to bacterial vulnerability and alteration of the nutrient transport and DNA.
• Calcium hydroxide also hydrolyzes the toxic lipid A of bacterial endotoxin into a toxic fatty acids and amino
sugars, thereby inactivating the inflammatory reaction and periapical bone resorption.
Camila Maggi Maia Silveira et al. Apexification of an Immature Permanent Incisor with the Use of Calcium Hydroxide: Case Reports in Dentistry
Volume 2015, Article ID 984590, 6 pages http://dx.doi.org/10.1155/2015/984590
Ca(OH)2 – role in apical barrier formation

• An alkaline environment neutralizes lactic acid from osteoclasts, avoiding dissolution of the dentin mineral
components.
• Calcium ions can induce expressions of type I collagen, osteopontin, osteocalcin, and alkaline phosphatase
enzyme in osteoblasts and mineralization through the phosphorylation of p38 mitogen-activated protein
kinase and cJun N-terminal kinase.
• Alkaline phosphatase liberates inorganic phosphatase from phosphate esters.
• It can separate phosphoric esters, releasing phosphate ions that react with bloodstream calcium ions to form
calcium phosphate of hydroxyapatite.
• Bone morphogenetic protein-(BMP-)2is a growth factor that is expressed in presence of calcium hydroxide.
• BMP-2 aids the regeneration of bone, cementum, and periodontal tissue.
• It may act as a mitogen for undifferentiated mesenchymal cells and osteoblast precursors, inducing
osteoblast phenotype expression, and as a chemoattractant for mesenchymal cells and monocytes.
• Additionally, BMP-2 may bind to extracellular matrix type Iv collagen.
• Calcium hydroxide also creates a necrotic zone by rupturing glycoproteins in the intercellular substance,
resulting in protein denaturation and granulation tissue
Camila Maggi Maia Silveira et al. Apexification of an Immature Permanent Incisor with the Use of Calcium Hydroxide: Case Reports in
Dentistry Volume 2015, Article ID 984590, 6 pages http://dx.doi.org/10.1155/2015/984590

Studies where CaOH was used to induce apical barrier formation (ABF) and healing.
Study Number oftreated
teeth
CaOH used Time for
ABF
range/me
an
Success Rates
Thater et al., 1988 34 Pulpdent Not stated 74%
Mackie et al., 1988 112 Reogan-Rapid 10.3mo 96%
Yates, 1988 22 teeth-study grp
22 teeth-control grp
CaOH powder
& sterile water
or Hypocal
9 mo study grp
20.2 mo control group
100%
Kleier et al., 1991 48 CaOH paste
& Pulpdent
1.6y, 1-30 mo. 100%
Mackie et al., 1994 19 Reogan-Rapid 6.8 mo 100%
19 Hypocal 5.1mo 100

Apexification was attempted with either calcium hydroxide mixed with sterile distilled water, or
calcium hydroxide plus iodoform in methyl cellulose base, or calcium hydroxide plus iodoform in
polysilicone oil base
Contemporary Clinical Dentistry | Jan-Mar 2014 | Vol 5 | Issue 1

Controversies on calcium hydroxide dressing changing
Study Findings Advantage
Chawla 1986 it suffices to place the paste only once and
wait for radiographic evidence of barrier
formation
Chosack et al 1972 the initial root filling with calcium hydroxide
there was nothing to be gained by repeated root
filling either monthly or after 3 months
Abbot 1998 radiographs cannot be relied
upon
the ideal time to replace a dressing depends on
the stage of treatment and the size of the
foramen opening.
It allows clinical assessment of
barrier formation and may
increase the speed of bridge
formation

Time required for apical barrier formation in apexification using calcium hydroxide
Sheehy and Roberts 1997 an average length of time for apical barrier formation ranging from 5
to 20 months
Finucane and Kinirons 1991 calcium hydroxide apexification and found that the mean time to
barrier formation was 34.2 weeks (range 13–67 weeks)
Cvek 1972 infection and/or the presence of a periapical radiolucency at the start
of
treatment increases the time required for barrier formation
Kleier and Barr 1991 presence of symptoms the time required for apical closure was
extended by approximately 5 months to an average of 15.9 months

According to Cruz et al.1998., histological analysis of the apical barrier
• Outer surface of the bridge extended in a ‘caplike’.
• The histological sections showed distinctlayers.
• Dense acellular cementum-liketissue.
• Irregular dense fibrocollagenous connective tissue with irregularfragments of highly mineralized calcifications.
Progonosis:
The root is under developed and tooth is fragile. It is prone to fracture from minimal trauma.

4 patterns of closure following apexification by Frank
• Continued apical development with a definite though minimal, recession of the root
canal.
• Continued apical development without any change in the root canal space (dome
apexification )
• Thin calcific bridge, formation at the apex without apical development.
• Lack of apical development with a calcific bridge just coronal to the apex.

Five outcomes of apexification procedure (weine):
• No radiographic change is apparent; but if instrumentis inserted, a blockage at the apex is encountered.
• Radiographic evidence of calcified material is seen at or near the apex.
• Apex closes without any change in canal space.
• Apex continues to develop with closure of the canal apace.
• No radiographic evidence of change is seen, and clinical symptom and/or development of or the increase in size of
periapical lesion occurs. This would need either re- treatment with Calcium hydroxide or surgery.
Inherent disadvantages of calcium hydroxide apexification
• Variability of treatment time
• Unpredictability of apical closure
• Difficulty to patient follow up
• Delayed treatment

• Apical Barrier Technique
• In 1979,Coviello & Brilliant reported the use of Tricalcium phosphate as an apical barrier.
• The material was packed into the apical 2mm of the canal against which GP was condensed. The treatment was achieved
in one appointment .
• Using radiographic assessment, they reported successful apexification comparable to that achieved with Calcium
hydroxide.
• Torabinejad and Chivian in 1999 advocated MTA as a material to serve as an apical barrier for root end induction.
• Because of its good sealing ability & High degree of biocompatibility, MTA would seem to be the material of choice for an
apical barrier.
procedure

Other material
Tricalcium Phosphate ( -
Tricalcium Phosphate(p -
TCP)Generic Tricalcium
Phosphate (g - TCP)
Freeze - dried cortical bone Freeze - dried Dentin allograft: Dentinal chips
Advantages:-
Biocompatibility
Exhibits low
inflammatory potential.
g- TCP is inexpensive,
g-TCP is easily available.
Advantages: -
Well tolerated by the tissue,
Capable of producing an
effective apical barrier,
Exhibits more complete and
rapid healing,
Prevents extrusion of the
obturating material.
Advantages: -
Used as apical barrier material.
Initially produces bone
resorption, but latter new hard
tissue formation appeared,
Exhibits minimal inflammation
in periapical region.
Advantages: -
Prevents overfilling of
obturating materials.
Effective in confining the
irrigation solutions to the canal
space
Leads to quicker healing
Minimal inflammation.
Stimulates osteogenesis or
cementogenesis.
Disadvantage :-
.- TCP was expensive
g - TCP packs tightly in
canal fins & isthmuses,
it is not removed by
NaOCI.
Disadvantage: -
Dentin chips, if infected, are a
serious deterrent to healing &
may actually irritate & hinder
repair.

MTA ( Mineral trioxide aggregate)
• Mineral trioxide aggregate (MTA) was first developed by Torabinejad and members at the Loma Linda
University, California, USA
• Initially it was used as a root-end filling material in endodontic treatment
• It is a mixture of dicalcium silicate, tricalcium silicate, tricalcium aluminate, gypsum, tetracalcium
aluminoferrite and bismuth oxide
• The addition of bismuth powder makes it radio opaque
• Original grey and a newer white
COMPOSITION OF GREY AND WHITE MTA

• Physical and chemical properties
1. Ph
• MTA has a pH similar to that of calcium hydroxide of12.5
• This similarity with calcium hydroxide is thought to contribute to its inductive potential and the resultant hard tissue
formation.
• The pH of MTA as it set was measured with a pH meter using a temperature-compensated electrode.
2. Sealing ability & marginal adaptation
The quality of apical seal for different retrograde materials has been assessed by different research groups, based on the
degree of penetration by
• dye
• radio-isotope
• bacterial
• electro-chemical means and
• fluid filtrationtechniques

• MTA is also associated with less overfills and the superior outcome associated with the material is observed with or
without blood contamination of the root cavities
• In a study carried out by Fischer et al.1998, using bacterial leakage model, the time period in which materials began
leaking was 10-63 days for amalgam, 24- 91 days for IRM.
• MTA did not begin to leak till day 49.
• The superior sealing ability of MTA is thought to be due to the setting expansion it undergoes in moist environment
COMPRESSIVE STRENGTH
• MTA has a relatively low compressive strength; however, this does not compromise its success as it is used in situations
that experience low compressive forces.
• Sluyk et al..(1998) studied setting properties of MTA and found that MTA reached its maximum resistance level if left
undisturbed for 72 hours before placement of a permanent restoration

• BIOCOMPATIBILTY
• Material analysis of MTA shows the material to be divided into calcium oxide and calcium phosphate.
• The scanning electron microscopic studies revealed that amorphous calcium phosphate showed maximum ingress and
growth of cells.
• They concluded that MTA offers a biological substrate for osteoblasts and the calcium phosphate phase favored the
change in cell behaviour that stimulated growth over MTA
INDUCTIVE POTENTIAL
• Torabinejad et al. and colleagues 1995 used infected premolars in two-year old beagle dogs, which were prepared to
receive gutta-percha root-fillings
• The root fillings were left to contaminate by means of open access cavities and subsequently underwent root resection
and retrograde fillings with either MTA or amalgam
• Although periosteum and new bone formation were found in the presence of both materials, histologic findings at 10-
18 weeks post-surgery confirmed the formation of cementum exclusively over the root ends with MTA, which
included the MTA itself.

• Cytotoxicity
An in vitro study conducted by Osorio et al. in 1998 compared different root canal sealers and root end filling materials
using two assay systems and two different mammalian fibroblast cell line .
Their conclusions were based on the fact that if a material exhibits a strong cytotoxicity in cell culture tests, it is very
likely to do so in living tissue. Of the materials tested, MTA was the least cytotoxic.

• MTA and biodentine being bioactive dental materials can be successfully used for root end closure of open apices.
• Host response was same in both teeth.
• Hence, it was concluded that biodentine showed better initial healing while MTA had better long-term effect.
• It was concluded that initial healing was better in the case of biodentine while long-term effect of MTA was better.
Elumalai D, Kapoor B, Tewrai RK, Mishra SK. Comparison of mineral trioxide aggregate and biodentine for
management of open apices. J Interdiscip Dentistry 2015;5:131-5.
Sridhar et al.,(2010)
• The aim of the case reports was to present a treatment to promote root-end growth and
apexification in nonvital immature permanent teeth in children.
• Three cases were presented where the calcium hydroxide and iodoform paste Metapex® was placed
in the root canals of immature permanent teeth using disposable plastic tips.
• At the end of 12 months all the cases showed continued root growth andapical closure
(apexification) with no evidence of periapical pathology.
Conventional endodontic treatment was then performed.

Biodentin
Composition Of Biodentine
Powder
• Tri-calcium silicate- This is the main core material.
• Di-calcium silicate- this is the second core material
• Calcium carbonate & oxide- it acts as a filler.
• Iron oxide-it acts as a colouring agent.
• Zirconium oxide- it acts as a radioopacifier.
Liquid
Calcium chloride- it acts as an accelerator.
Hydrosoluble polymer- it is a water reducing agent.
Setting Time- approximately 12-14 minutes.

Mechanism Of Action
• Biodentine induces mineralization after its application.
• Mineralization occurs in the form of osteodentine by expressing markers of odontoblasts & increases TGF-Beta1 secretion
from pulpal cells enabling early mineralization.
• During the setting of the cement Calcium hydroxide is formed. Due to its high pH, Calcium hydroxide causes irritation at
the area of exposure. This zone of coagulation necrosis has been suggested to cause division and migration of precursor
cells to substrate surface; addition and cytodifferentiation into odontoblast like cells.
• Thereby Biodentine induces apposition of reactionary dentine by odontoblast stimulation and reparative dentin by cell
differentiation ,Because of its high alkality it has inhibitory effects on microorganism.

• Properties
Tissue Regeneration & Early Mineralisation
✓ Biodentine induces early minerlization by increasing the secretion of TGF-ϐ1 from pulpal cells after its application
✓ It also acts by odontoblasts stimulation and cell differentiation, there by facilitating reactionary and tertiary dentin
formation.
✓ The study results suggested that biodentine is bioactive because it increased OD21 cell proliferation and it can be
considered as a suitable material for clinical indications of dentine-pulp complex regeneration.
Short setting time
Anti bacterial properties
Bio compatibility
Good material handling
Mariginal Adaptation and Sealing Ability= The micromechanical adhesion of biodentine is caused by the alkaline effect
during the setting reaction. This high pH causes organic tissues to dissolve out of the dentin tubule. The alkaline environment
at the boundary area of contact between biodentine and hard tooth substance opens a path via which the dentin substitute
mass can enter the exposed opening of the dentin canaliculi

Jia-Cheng Lin Comparison of mineral trioxide aggregate and calcium hydroxide for apexification of immature permanent teeth: A systematic
review and meta-analysis journal of Formosan medical ass. 2016

• Regenerative Biomaterials
• American Association of Endodontists’ Glossary of Endodontic Terms defines regenerative endodontics as “biologically-
based procedures designed to physiologically replace damaged tooth structures, including dentin and root structures, as
well as cells of the pulp-dentin complex.”
• In 2004, Banchs and Trope published a case report describing a new treatment procedure for the management of the
open apex called “revascularization.”
• Unlike traditional apexification or the use of apical barriers, revascularization procedures allow for increase in both the
length of the root and root wall thickness.
• Hargreaves et al. recommended three major components of pulp regeneration which require further research for the
development of pulpal regeneration:
a) a reliable cell source capable of differentiating into odontoblasts
b) an appropriate scaffold to promote cell growth and differentiation
c) signaling molecules, both growth factors and other compounds, that are capable of stimulating cellular proliferation and
directing cellular differentiation
AAE Position Statement – Scope of Endodontics: Regenerative Endodontics,2014

Role of scaffold in revascularization
• Scaffold provides a physiochemical and biological three dimentional micro-environment for cell growth and
differentiation, promoting cell adhesion and migration.
• Scaffold is used to guide, organize, provide physical and chemical signals and help in growth and
differentiation of cells.
• Tissues are composed of cells, insoluable extracellular matrix and soluble serving as regulators of cell
function.
• ECM consist of collagen, glycoprotein and proteoglycan and it is important for growth and function of
different cells involved.
• PRP is autologous , easy to prepare scaffold, rich in growth factors, degrades and form 3 dimentional fibrin
network

Rationale of Revascularization :According to Windley et al.(2005)
• 1. Canal disinfection: This is regarded as a key factor for successful treatment.
• 2. Scaffold placement in the canal for the growing tissues: Once canal disinfection has been completed, the apex is
mechanically irritated to induce clot formation, which will serve as a scaffold for tissue generation.
• 3. Bacteria-tight sealing of the access aperture
Irrigants
• 2.5–5.25% NaOCl
• 3% hydrogen peroxide
• 17% EDTA
• 0.12%-2% CHX. - may be detrimental to the stem cells
Intracanal medicaments
Triple antibiotic paste (a 1:1:1 mixture of ciprofloxacin/
metronidazole/ minocycline or variation), Ca(OH)2 alone or
in combination with antibiotics or formocresol.
Calcium hydroxide as an intra-canal medicament for
revascularization - damages the remaining pulp tissue, apical
papilla and HERS.
Rohit Pannu Pulp revascularisation - An evolving concept: A review , International Journal of Applied Dental Sciences 2017; 3(4): 118-121

Mechanism of Revascularization:
• Continued root development could be due to multipotent dental pulp stem cells. These cells from the apical end might be
seeded onto the existing dentinal walls and might differentiate into odontoblasts and deposit tertiary or atubular dentin.
Second possible mechanism
• could be attributed to the presence of stem cells in the periodontal ligament which can proliferate, grow into the apical
end and within the root canal, and deposit hard tissue both at the apical end and on the lateral root walls
Third possible mechanism
• could be that the blood clot itself, being a rich source of growth factors, could play an important role in regeneration.
These include plateletderived growth factor, vascular endothelial growth factor (VEGF), platelet-derived epithelial growth
factor, and tissue growth factor and could stimulate differentiation, growth, and maturation of fibroblasts, odontoblasts,
cementoblasts, etc from the immature, undifferentiated mesenchymal cells in the newly formed tissue matrix
Rohit Pannu Pulp revascularisation - An evolving concept: A review , International Journal of Applied Dental
Sciences 2017; 3(4): 118-121

M.NamourandS.Theys ReviewArticle Pulp Revascularization of Immature Permanent Teeth: A Review of the Literature and a Proposal of a New Clinical Protocol
Volume 2014, Article ID 737503, 9 pages

Advantages of revascularization:
• Requires a shorter treatment time- after control of infection,can be completed in a single visit.
• Cost-effective- the number of visits is reduced, and no additional material (such as TCP, MTA) is required.
• Obturation of the canal is not required unlike in calcium hydroxide– induced apexification, with its inherent danger of
splitting the root during lateral condensation.
• -Continued root development (root lengthening) and strengthening of the root as a result of reinforcement of lateral
dentinal walls with deposition of new dentin/hard tissue.
Technically simple and can be completed using currently available instruments and medicaments without expensive
biotechnology.
✓ Regeneration of tissue in root canal systems by a patient’s own blood cells avoids the possibility of immune rejection
and pathogen transmission from replacing the pulp with a tissue engineered construct.

DRAWBACKS OF REVASCULARIZATION
• The reliance on patient’s compliance to carry out the procedure in multiple visits and the lack of long term follow-up
studies makes revascularization procedure a supplement but not a substitute to the already existing treatment protocols
like apexogenesis, apexiﬁcation, or partial pulpotomy.
• Also, the concentration and composition of the progenitor/stem cells entrapped in the ﬁ brin clot is unpredictable,
particularly in older patients and may lead to disparity in the results.
Limitations of revascularization
• Long-term clinical results are as yet not available.
• Entire canal might be calcified, compromising esthetics and potentially increasing the difficulty in future endodontic
procedures if required.
• In case post and core are the final restorative treatment plan, revascularization is not the right treatment option because
the vital tissue in apical two thirds of the canal cannot be violated for post placement.
Vemuri, et al.: Root canal revascularization via blood clotting Journal of Dr. NTR University of Health Sciences 2013;2(4)

MTP ALBUQUERQUE et al. Pulp revascularization: an alternative treatment to the apexification of immature teeth
RGO, Rev Gaúch Odontol, Porto Alegre, v.62, n.4, p. 401-410, out./dez., 2014

Bone morphogenic proteins (BMP)
• Bone morphogenic proteins (BMPs) are a generic term for a family of proteins which have bone-inductive properties.
• It was observed as early as in 1965 by Marshell Urist that demineralized bone matrix was capable of stimulating bone
formation when implanted in ectopic sites.
• They have a pivotal role in regulation of bone induction maintenance & repair
Misako Nakashima, A Hari Reddi The application of bone morphogenic
proteins to dental tissue engineering : Nature Biotechnology .2003: 21 ( 9).
❑Mechanism of action
Nakashima in 1990 demonstrated that BMP affect by induction of a layer of reparative dentine.
Firstly, they stimulate proliferation of pulp stem cells and induce their differentiation into
odontoblast to enhance healing potential and rapid dentine formation.
Secondly, they act by increasing the thickness of remaining dentine and reducing direct
connection between tubules of primary dentine and the reparative dentine

Platelet rich plasma (PRP) and PRF
• Although with the discovery of bone morphogenic protein a new chapter has been opened in reconstructive and
regenerative sciences. But the relative effectiveness and the successful application of bone morphogeniç proteins (BMPs)
depends on elucidation of the optimal therapeutic dosage, delivery system, and local conditions for repair and this led to
introduction of platelet rich plasma (PRP) and later PRF .
❑ Mechanism of action
• found to work via three mechanisms:
1. Release of Growth Factors
• increases local cell division (producing more cells).
2. Inhibition of excess inflammation
• (decreased early macrophage proliferation).
3. Degranulation of the agranules in platelets, which contain the synthesized and prepackaged growth factor.
M.NamourandS.Theys ReviewArticle Pulp Revascularization of Immature Permanent Teeth: A Review of the Literature and a Proposal of a New Clinical Protocol
Volume 2014, Article ID 737503, 9 pages

Dental pulp stem cells ( DPSC) :
• DPSCs has the ability to regenerate a dentin-pulp-like complex that is composed of mineralized matrix with tubules
lined with odontoblasts, and fibrous tissue containing blood vessels in an arrangement similar to the dentin-pulp
complex found in normal human teeth (Gronthos S., et al. 2003).
• DPSCs possess the properties of high proliferative potential, the capacity of self-renewal, and multi-lineage
differentiation. (Gronthos S., et al.2005).
Mechanism of action of DPSC: (Miura M., et al 2003)
Following physiological stimulation or injury, such as caries and operative procedures, stem cells in pulp can
proliferate and differentiate into dentinforming odontoblasts (Nakashima et al., 1994; Gronthos et al., 2000,
2002).
Replace damaged odontoblasts by newly generated populations of odontoblasts.

Following physiological stimulation or injury, such as caries and operative procedures, stem
cells in pulp can proliferate and differentiate into dentinforming odontoblasts

Modified apexification technique
• This is alternative technique to traditional apexification technique for root development
• A modified apexification procedure provides immature permanent teeth with necrotic pulp/apical periodontitis requiring a post/core for a
final restoration the potential of continued apical root development, which is an advantage over current apical barrier techniques.
Criteria
• Immature permanent teeth that have lost substantial coronal structure for final proper restoration.
• Immature permanent tooth with stage 3-4 root development
Kamolthip Songtrakul, Modified Apexification Procedure Case Series , JOEVolume -, Number -, - 2019

Modified apexification technique is easier than traditional apexification procedure to perform because ,
MTA/ Biodentin apical plug does not have to be place close to the open apex.
It has potential to promote continued apical root development, thus increasing crown root ratio

80
TECHNIQUE/
MATERIAL
INVESTIGATORS NO
CASES
OBSERV
ATIONS
OUTCOMES
Comparison of MTA
plug with CH therapy
El-Meligy andAvery,
2006
15 12 2 of CH teeth had become reinfected, but all teeth
treated with MTAplug remained successful
Comparison of MTA
plug with CH therapy
Pradhan et al, 2006 20 12 Periapical lesions resolved in 4.6 1.5 months for MTA group and
in 4.4 1.3 months for CH group. Total treatment was completed in
0.75 0.5 months for MTA group and 7 2.5 months for CH group.
MTAplug Pace et al, 2007 11 2 yrs 10 of 11 cases healed, and remaining case considered
incomplete healing
MTAplug Erdem and Sepet, 2008 5 2 yrs 4 of 5 teeth healed; 1 case in MTAwasextruded
MTAplug Sarris et al, 2008 17 11.7 yrs 94.1% clinical success, 76.5% radiographic success;
17.6% uncertain
MTAplug Holden et al, 2008 20 12-44
month
Healing rate was 93.75%

81
TECHNIQUE/
MATERIAL
INVESTIGATORS NO
CASES
OBSER
V
ATION
S
OUTCOMES
MTAplug Nayar et al, 2009 38 12
months
All teeth were clinically and radiographically
successful
MTAplug Annamalai and
Mungara, 2010
30 12
months
100% success clinically and radiographically
MTAplug Moore et al, 2011 22 Mean
follow-
up time
23.4
months
Clinical and radiographic success rate of 95.5%;
discoloration in 22.7% of teeth
MTAplug Simon et al, 2007 43 12
months
81% healed
MTAplug Witherspoon et al, 2008 78 Mean
recall
time was
19.4
months
93.5%of teeth treated in 1 visit healed, and 90.5% of teeth
treated in 2 visits healed

Non vital pulp therapy

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Non vital pulp therapy